Initial stabilization:
❑ Assess the airway
❑ Position the patient upright at an angle of 45 degrees, with legs dangling off the bedside
❑ Check pulse oximetry
❑ If hypoxemia is present (Sa02 < 90% or Pa02 <60 mmHg), administer oxygen with/without noninvasive ventilation
❑ Avoid IV morphine (may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms)
❑ Ensure continuous cardiac monitoring
❑ Secure intravenous access with 18 gauge cannula
❑ Monitor vitals signs
❑ Monitor fluid intake and urine output
Assess congestion and perfusion:
Congestion at rest (dry vs. wet)
"Wet" suggested by orthopnea, ↑JVP, rales, S3, pedal edema
Low perfusion at rest (warm vs. cold)
"Cold" suggested by narrow pulse pressure, cool extremities, hypotension
The patient is:
❑ Warm and dry, OR
❑ Warm and wet, OR
❑ Cold and dry, OR
❑ Cold and wet
Admit for in-hospital treatment if:
❑ Hypotension and/or cardiogenic shock
❑ Poor end-organ perfusion (worsening renal function, cold clammy extremities, altered mental status)
❑ Hypoxemia (Sa02 <90%)
❑ Atrial fibrillation with a rapid ventricular response resulting in hypotension
❑ Presence of an underlying condition, such as acute coronary syndrome
Identify precipitating factor and treat accordingly:
For more details on the manegemtn, click on the disease to be transferred to the resident survival guide
❑ 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)
❑ Atrial fibrillation
- Rate control of atrial fibrillation is the mainstay of arrhythmia therapy. Avoid the use of drugs with negative inotropic effects such as beta blockers and non-dihydropyridine calcium channel blockers e.g., verapamil in the treatment of acute decompensated systolic heart failure
- Consider cardioversion if the patient is in cardiogenic shock or if new onset atrial fibrillation is the clear precipitant of the hemodynamic decompensation
❑ COPD
❑ Pulmonary embolism
❑ 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)