Initial stabilization:
❑ Assess the airway
❑ Position the patient upright at an angle of 45 degrees, with legs dangling off the bedside (decrease preload)
❑ Monitor heart rate and blood pressure continuously
❑ Monitor oxygen saturation continuously
❑ If hypoxemia is present (Sa02 < 90% or Pa02 <60 mmHg), administer oxygen with/without noninvasive ventilation
❑ Morphine to decrease symptoms and Afterload (avoid IV morphine, may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms)
❑ Secure intravenous access with 18 gauge cannula
❑ Monitor fluid intake and urine output carefully (guide the adjustment of the diuretics dose)
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
Identify precipitating factor and treat accordingly:
Click on the precipitating factor for more details on the management
❑ 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
❑ Administer IV loop diuretics as intermittent boluses or continuous infusion (I-B)
- ❑ If patient is already on loop diuretics: IV dose ≥ home PO dose (I-B); rule of thumb: IV dose = 2.5x equivalent oral daily dose
- ❑ If patient is not already on loop diuretics, administer IV starting dose:
- Furosemide 20 to 40 mg, OR
- Torsemide 5 to 10 mg, OR
- Bumetanide 0.5 to 1 mg
- ❑ Adjust dose according to volume status (I-B)
- ❑ Perform serial assessment of fluid intake and output, vital signs, daily body weight (measured every day, with the same scale, at the same time, after first void) and symptoms
- ❑ Order daily electrolytes, BUN, creatinine (I-C)
❑ Low sodium diet (<2 g daily)
❑ In case of persistent symptoms:
- ❑ Increase dose of IV loop diuretics (I-B)- double dose at 2 hour interval up to maximal daily dose
- Furosemide maximal dose: 40 to 80 mg
- Torsemide maximal dose: 20 to 40 mg
- Bumetanide maximal dose: 1 to 2 mg
- 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) refractory to higher dose/combination of IV diuretics
Venodilators
❑ Consider IV nitroglycerin, nitroprusside, or nesiritide as add-on to diuretics to relieve dyspnes (IIb-A)
- Do not administer vesodilators among patients with hypotension.
Treat low perfusion:
❑ Inotropes (click her for details)
- If the total body and intravascular volumes are overloaded and the patient is normotensive, then diuresis alone should be undertaken. If the patient is volume overloaded but hypotensive, then inotropes must be administered in addition to diuretics.
Invasive hemodynamic monitoring:
❑ Consider pulmonary artery catheterization in case of failure to respond to medical therapy, respiratory distress, shock, uncertainty regarding volume status, or increase in creatinine; assess the following parameters:
- ❑ PCWP
- ❑ Cardiac output
- ❑ Systemic vascular resistance
VTE prevention:
❑ Anticoagulation in the absence of contraindications (I-B)
Chronic medical therapy:
❑ Chronic ACE inhibitor: Hold if patient is hemodynamically unstable
❑ Chronic beta blocker:
- Hold if patient is hemodynamically unstable and/or in need or inotropes
- Decrease dose by ≥ half if patient is in moderate heart failure
❑ DO NOT INITIATE ACE INHIBITORS during an acute decompensation
❑ DO NOT INITIATE BETA BLOCKER during an acute decompensation; initiate beat blockers at a low dose in stable patients following optimization of volume status and D/C IV diuretics and inotropes (I-B)
Monitor laboratory tests:
❑ BUN
❑ Creatinine
❑ Sodium (to detect hyponatremia which carries a poor prognosis), chloride, bicarbonate (to detect contraction alkalosis) and serum potassium (to detect hypokalemia as a result of diuresis and which can precipitate arrhythmias), potassium, magnesium
Management of hyponatremia:
❑ Water restriction
- ❑ <2 L/day if the Na is < 130 meq/L
- ❑ < 1 L/day or more if the Na is < 125 meq/L
- Keep in min that juices are essentially free water with sugar.
- In the hyponatremia patient, drips should not be in D5W.
❑ Optimization of chronic home medications
❑ Persistent
hyponatremia and risk of cognitive impairment: vasopressin antagonist for short term (hypervolemic)