Management

• Perform a rapid ABCDE survey to assess hemodynamic stability.

• Identify and treat any acute underlying cause of AHF for all patients.

• Clinical presentation: SBP > 90 mm Hg AND no signs of end-organ hypoperfusion; respiratory distress can be present.

• Management: depends on the classification of AHF

  • No evidence of congestion (dry and warm): Optimize oral therapy.

  • Evidence of congestion (wet and warm)

    • Start initial measures for respiratory support in AHF (e.g., positioning, supplemental O2) as needed.

    • Start diuretic therapy for AHF if there is volume overload.

    • Consider vasodilators for AHF, e.g., nitrates.

  • Morphine is no longer routinely recommended.

To remember the management of ADHF, think of “LMNOP”: Loop diuretics (furosemide), Modify medications, Nitrates, Oxygen if hypoxic, Position (with elevated upper body).

• Clinical presentation: can vary

  • Cardiogenic shock: SBP < 90 mm Hg OR signs of end-organ hypoperfusion

  • Hypertensive emergency: hypertension (e.g., SBP > 180 mm Hg) PLUS flash pulmonary edema and hypoxemic respiratory failure

• Management: depends on the classification of AHF (See also “Management of cardiogenic shock.”)

  • Evidence of congestion with shock (wet and cold)

    • Prioritize respiratory support for AHF.

    • Consider inotropic support (e.g., dobutamine, norepinephrine).

  • Shock without evidence of congestion (dry and cold): Consider fluid challenge; add vasopressors and inotropes for shock refractory to fluids.

  • Hypertensive emergency with flash pulmonary edema (wet and warm)

    • Begin NIPPV and vasodilators for AHF. [35][37][38]

    • Identify and treat the underlying trigger.

• Fluid restriction

• Sodium restriction

• Identify and treat comorbidities (e.g., atrial fibrillation, pneumonia, COPD) and underlying triggers.

• Administer beta blockers cautiously in beta-blocker-naive patients.

  • Start at a low dose.

  • Administer only after stabilization (e.g., after volume status has been optimized and IV diuretics, vasodilators, and inotropic agents have been discontinued) [7][35]

• Initiate, adjust, or continue medical treatment of heart failure as needed.

• Optimize blood pressure control (

• Administer beta blockers cautiously in beta-blocker-naive patients.

  • Start at a low dose.

  • Administer only after stabilization (e.g., after volume status has been optimized and IV diuretics, vasodilators, and inotropic agents have been discontinued)

• Initiate, adjust, or continue medical treatment of heart failure as needed.

• Optimize blood pressure control

For patients not previously on beta blockers, use cautiously and only once the patient has been stabilized.

Consider the following if AHF persists despite maximal respiratory and hemodynamic support.

• Ultrafiltration (e.g., hemodialysis): indicated in congestion with no response to medical therapy

• Mechanical circulatory support: indicated in reversible refractory acute heart failure

• Management of effusions: Consider therapeutic thoracentesis or pericardiocentesis as needed.

• Positioning: Ensure the patient is sitting upright. [47]

• Supplemental oxygen: indicated for patients with an SpO2 < 90% or PaO2 < 60 mm Hg

• NIPPV: for patients with respiratory distress despite supplemental oxygen

• Invasive mechanical ventilation

  • Indications

    • Hypoxemic respiratory failure unresponsive to NIPPV

    • Refractory hypoxemia (PaO2 < 60 mm Hg)

    • Hypercapnia (PaCO2 > 50 mm Hg)

    • Acidosis (pH < 7.35)

EPAP and/or PEEP should be used with caution in patients with hemodynamic compromise.

Initial treatment

• Administer diuretics intravenously, if possible.

• Diuretic-naive patients: IV furosemide OR bumetanide

Continuing treatment

• Dosage adjustment: Assess the effect of diuretics (e.g., urine output, symptoms) every 6 hours.

• Refractory AHF (despite high doses of loop diuretics): Consider any of the following.

  • Combination therapy with a thiazide diuretic, e.g., metolazone, hydrochlorothiazide, chlorothiazide [5][54]

  • Addition of a vasodilator for AHF [5]

Monitoring

• Monitor and replete serum electrolytes.

• Monitor renal function (creatinine levels).

Indications

• Acute heart failure caused by hypertensive emergency (see “Treatment of hypertensive crises”)

• Flash pulmonary edema

• Adjuvant to diuretics for symptomatic relief of dyspnea

Treatment options

• IV nitroglycerin

• Sodium nitroprusside

• If there are contraindications to nitroglycerin, consider nesiritide.

Avoid the use of vasodilators in patients with acute heart failure and hypotension.