Management of Acute Decompensated Heart Failure

Initial Assessment and Stabilization

The European Society of Cardiology recommends determining cardiopulmonary stability by assessing respiratory distress and hemodynamic status 1, 2
The European Society of Cardiology suggests establishing continuous monitoring including pulse oximetry, blood pressure, respiratory rate, and ECG within minutes of patient contact 1, 2
Assess mental status using the AVPU mnemonic as an indicator of hypoperfusion, as recommended by the European Heart Journal 2, 3
Position patient upright to reduce work of breathing and improve ventilation, according to the European Journal of Heart Failure 4
Administer oxygen therapy if SpO₂ <90% with a target of maintaining SpO₂ >90%, as recommended by the European Society of Cardiology 1, 2
Initiate non-invasive ventilation in patients with respiratory distress to improve clinical parameters and reduce work of breathing, according to the European Heart Journal 2, 4, 5

Obtain ECG to exclude ST elevation myocardial infarction and assess for other cardiac abnormalities, as recommended by the European Society of Cardiology 1, 2
Order laboratory tests including cardiac biomarkers, BUN/creatinine, electrolytes, complete blood count, natriuretic peptides, and glucose, according to the European Journal of Heart Failure 1, 4
Perform chest X-ray to rule out alternative causes of dyspnea, as recommended by the European Society of Cardiology 1, 2
Consider bedside thoracic ultrasound for signs of interstitial edema if expertise is available, according to the European Journal of Heart Failure 1, 2

Administer IV loop diuretic, with an initial dose of 2-2.5 times the patient's home dose, as recommended by the European Journal of Heart Failure 5
Consider IV vasodilators titrated according to blood pressure, according to the European Heart Journal 6
Consider morphine in early stages, especially with severe dyspnea, restlessness, or anxiety, as recommended by the European Journal of Heart Failure 5

Monitor vital signs continuously, including blood pressure, heart rate, respiratory rate, and oxygen saturation, as recommended by the European Society of Cardiology 1, 3
Assess urine output to evaluate response to diuretic therapy, according to the European Journal of Heart Failure 4

Avoid excessive oxygen therapy in patients with COPD, targeting SpO₂ >90% rather than 95%, as recommended by the European Journal of Heart Failure 5
Be cautious with NIV in patients with cardiogenic shock and right ventricular failure, according to the European Journal of Heart Failure 5
Recognize that troponin may be elevated in ADHF without acute coronary syndrome, making it difficult to exclude ACS, as noted by the European Journal of Heart Failure 4
Immediate echocardiography is mandatory in patients with cardiogenic shock, but can be performed after stabilization in other cases, as recommended by the European Society of Cardiology 1, 2

Patients with respiratory failure or hemodynamic compromise should be admitted to a location where immediate respiratory and cardiovascular support can be provided, as recommended by the European Heart Journal 2, 7
Stable patients can be managed in observation units or regular wards after initial stabilization, according to the European Journal of Heart Failure 7
Consider early cardiology consultation, especially for patients with de novo heart failure, as recommended by the European Heart Journal 2, 7