Sandbox Rim
Treatment of Acute Decompensation of Heart Failure
Initial stabilization:
- Oxygen with/without noninvasive ventilation
- Sit up and have legs dangling off the bedside
- Morphine
Assess congestion and perfusion:
- Warm and dry (outpatient treatment), OR
- Warm and wet (Diuresis +/- vasodilator), OR
- Cold and dry (Admission to CCU: with/without inotropes), OR
- Cold and wet (Admission to CCU: diuresis, with/without inotropes)
Admit for in-hospital treatment if:
Identify precipitating factor and treat accordingly:
- Myocardial infarction
- Myocarditis
- Renal failure
- Hypertensive crisis
- Non adherence to medications
- Worsening aortic stenosis
- Drugs (NSAIDS, thiazides, calcium channel blocker, beta blockers)
- Toxins (alcohol, anthracyclines)
- Arrhythmia
- COPD
- PE
- Anemia
- Thyroid abnormalities
- Systemic infection
Treat congestion and optimize volume status:
Diuretics
- IV loop diuretics as intermittent boluses or continuous infusion (I-B)
- Already on loop diuretics: IV dose >= home PO dose (I-B)
- Serial assessment of fluid intake and output, vital signs, body weight (measured every day at the same time) and symptoms
- Adjust dose according to volume status (I-B)
- Daily electrolytes, BUN, creatinine (I-C)
- Persistent symptoms: Increase dose of IV loop diuretics (I-B) OR Add a second diuretics, such as thiazide (I-B)
- Consider low dose dopamine infusion for improved diuresis and renal blood flow (IIb-B)
- Consider renal replacement therapy/Ultrafiltration in obvious volume overload (IIb-B)
Venodilators
- Consider IV nitroglycerin, nitroprusside, or nesiritide as add-on to diuretics to relieve dyspnea (IIb-A)
Treat low perfusion:
- Inotropes
VTE prevention:
- Anticoagulation in the absence of contraindications (I-B)
Chronic medical therapy:
- Chronic HFrEF and hemodynamically stable: continue medical therapy
- Initiate beat blockers at a low dose in stable patients following optimization of volume status and D/C IV diuretics and inotropes (I-B)
Management of hyponatremia:
- Water restriction
- Optimization of chronic home medications
- Persistent hyponatremia and risk of cognitive impairment: vasopressin antagonist for short term (hypervolemic)