Heart Failure Management

Initial Assessment and Stabilization

Determine severity of cardiopulmonary instability based on respiratory distress, hemodynamic status, and heart rhythm, particularly in patients with respiratory rate >25/min, SpO2 <90%, increased work of breathing, or signs of hypoperfusion 1
Administer oxygen immediately if SpO2 <90% to improve oxygen saturation, with a target saturation of 93-98% in most patients and 88-92% in those with COPD or at risk of hypercapnic respiratory failure 1, 2, 3, 4, 5
For patients with persistent respiratory distress despite oxygen, initiate non-invasive positive pressure ventilation (NIPPV), with CPAP preferred in pre-hospital setting and pressure support ventilation with PEEP (PS-PEEP) preferred for patients with acidosis and hypercapnia, and initial settings for NIV: PEEP 5-7.5 cmH2O 1, 2, 6, 1, 5
Arrange rapid transfer to appropriate facility, preferably with cardiology department and/or CCU/ICU, and continue monitoring during transfer 1

Medication Management

The European Society of Cardiology recommends administering IV vasodilators and diuretics, with IV diuretics as first-line therapy, and considering vasodilators as initial therapy for hypertensive ADHF 1, 2
Administer IV diuretics as either intermittent boluses or continuous infusion, with initial recommended dose of 20-40 mg IV furosemide (or equivalent) for new-onset ADHF, and at least equivalent to oral dose for chronic diuretic therapy 2, 7, 1, 8
Evidence-based medications for HFrEF should be continued or initiated when hemodynamically stable, including beta-blockers, ACE inhibitors/ARBs, mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors, with careful titration and monitoring of renal function and potassium levels 7, 9, 10, 11
Beta-blockers should be started with a low dose of an evidence-based beta-blocker (bisoprolol, metoprolol succinate, or carvedilol) and slowly uptitrated, doubling the dose every 1-2 weeks as tolerated, while monitoring heart rate, blood pressure, and signs of worsening heart failure 11, 12, 13
Avoid inotropes unless patient is symptomatically hypotensive or hypoperfused due to safety concerns, and limit dobutamine use to short-term treatment 2
Never abruptly discontinue beta-blockers unless absolutely necessary due to the risk of rebound ischemia/infarction and arrhythmias, as warned by the European Society of Cardiology 14
Avoid intravenous non-dihydropyridine calcium channel antagonists, IV beta-blockers, and dronedarone in patients with decompensated heart failure, as advised by the American Heart Association 15
NSAIDs should be strictly avoided as they can worsen both heart failure and renal function, and the risk of intolerance to ACE inhibitors increases with concomitant NSAID use 16, 11
Calcium channel blockers should not be used for heart failure treatment 17

Diagnostic Evaluation

The following diagnostic tests are recommended to evaluate the underlying cause of dyspnea:

Test	Purpose
ECG	Rule out acute coronary syndrome and assess for arrhythmias
Chest X-ray	Confirm pulmonary edema and rule out alternative causes of dyspnea
BNP or NT-proBNP	Evaluate for heart failure
Troponin	Evaluate for myocardial injury
Complete blood count	Evaluate for anemia or infection
Electrolytes	Evaluate for electrolyte imbalances
BUN and creatinine	Evaluate for renal function
Arterial blood gas	Evaluate for respiratory distress

Patient Education and Follow-up

Comprehensive written discharge instructions should cover medication regimen, daily weight monitoring, dietary sodium and fluid restrictions, activity recommendations, follow-up appointments, and signs/symptoms requiring medical attention, as suggested by the American Heart Association 18
The American College of Cardiology recommends providing comprehensive written discharge instructions covering diet, discharge medications, activity level, follow-up appointments, daily weight monitoring, and instructions on what to do if heart failure symptoms worsen 7
Perform medication reconciliation at discharge to ensure accuracy 7
Daily assessment of fluid intake and output, body weight, vital signs, clinical signs of congestion and perfusion, and electrolytes, BUN, and creatinine is recommended 7, 14
Continuously monitor vital signs, oxygen saturation, urine output, renal function, and electrolytes to adjust diuretic dose based on response, symptoms, and clinical status 2
Monitor heart rate, blood pressure, clinical status (symptoms, signs of congestion, body weight), and laboratory results, including blood chemistry 12 weeks after initiation and 12 weeks after final dose titration 14
For increasing congestion, double the diuretic dose and/or halve the beta-blocker dose, as recommended by the European Society of Cardiology 14
For marked fatigue/bradycardia, halve the beta-blocker dose 14