Initial Management of Congestive Heart Failure

Immediate Assessment and Monitoring

The European Society of Cardiology recommends establishing non-invasive monitoring including pulse oximetry, blood pressure, respiratory rate, and continuous ECG within minutes of patient contact 1
The European Society of Cardiology suggests monitoring dyspnea (using visual analog scale), heart rate and rhythm, urine output, and peripheral perfusion 2
Positioning the patient upright can reduce the work of breathing, as recommended by the European Society of Cardiology 3
Assessing the severity of heart failure using respiratory rate (>25/min), SpO2 (<90%), and work of breathing is recommended by the European Society of Cardiology 1

The European Society of Cardiology recommends providing oxygen therapy if oxygen saturation <90% or based on clinical judgment 1
Initiating non-invasive ventilation (NIV) immediately in patients showing respiratory distress is recommended by the European Society of Cardiology 3
Using continuous positive airway pressure (CPAP) in the pre-hospital setting is suggested by the European Society of Cardiology, as it requires minimal training and equipment 3
Considering pressure-support positive end-expiratory pressure (PS-PEEP) for patients with acidosis and hypercapnia, particularly those with COPD history, is recommended by the European Society of Cardiology 3

Administering intravenous loop diuretics promptly is recommended by the European Society of Cardiology 3
The European Society of Cardiology suggests considering vasodilators for patients with normal to high blood pressure (SBP >110 mmHg) 3
Avoiding routine use of opioids, as they are associated with higher rates of mechanical ventilation, ICU admission, and death, is recommended by the European Society of Cardiology 3

Measuring plasma natriuretic peptide level (BNP, NT-proBNP, or MR-proANP) in all patients with acute dyspnea and suspected AHF is recommended by the European Society of Cardiology 4
Performing basic laboratory assessments including troponin, BUN (or urea), creatinine, electrolytes, glucose, and complete blood count is suggested by the European Society of Cardiology 4
Considering chest X-ray to identify pulmonary venous congestion, pleural effusions, and interstitial or alveolar edema is recommended by the European Society of Cardiology 4

Reassessing clinical, biological, and psychosocial parameters regularly is recommended by the European Society of Cardiology 2
Considering admission to intensive care unit/coronary care unit for patients with severe respiratory distress or hemodynamic instability is suggested by the European Society of Cardiology 1
Planning for follow-up with a cardiologist within 1-2 weeks is recommended by the European Society of Cardiology 2

For patients with heart failure and atrial fibrillation, considering intravenous cardiac glycosides for rapid control of ventricular rate is recommended by the European Society of Cardiology 3
Beta-blockers are preferred first-line treatment for ventricular rate control in patients with HF and AF, according to the American College of Cardiology 3
In patients with preserved ejection fraction (HFpEF), considering other causes of dyspnea and edema, including kidney disease, liver disease, chronic venous insufficiency, or specific cardiomyopathies, is recommended by the American College of Cardiology 5, 6

Delaying treatment is not recommended, as the "time-to-treatment" concept is important in AHF patients, according to the European Society of Cardiology 1
Avoiding routine use of morphine in AHF patients is recommended by the European Society of Cardiology 3
Not assuming all patients with dyspnea and edema have heart failure, and considering non-cardiac mimics, is suggested by the American College of Cardiology 5, 6
Avoiding invasive mechanical ventilation if possible by early use of non-invasive ventilation in appropriate patients is recommended by the European Society of Cardiology 3