Management plans vary based on clinical state and underlying cause, but most patients will require admission.

Treatment Principles (Acute and Chronic):

1. Preload reduction: Diuretics, Nitroglycerin, Restrict fluid/sodium.
2. Afterload reduction: ACE-I, Nitroglycerin, Intra-aortic Balloon Pump (IABP).
3. Increase contractility: Milrinone, Dobutamine, Ventricular Assist Device (VAD).
4. Decrease myocardial work: Beta-blockers, Ivabradine, IABP, VAD.
5. Increase coronary perfusion: Stents, CABG, IABP.

General ED Treatment Approach:

1. Respiratory distress

• Oxygen to keep O2 sat > 90%.
• Non-Invasive Ventilation (NIV).
  • respiratory distress (SpO₂<90%, RR >25) despite high flow O₂.
• Intubation if NIV/medical treatment fail or patient crashing.
• Nitroglycerin decreases pulmonary congestion improving respiratory status.

2. Volume overload

• Hypertensive/normotensive & perfusing well.
  • Majority of patients.
  • Nitroglycerin spray or IV infusion.
  • Loop diuretics +/- non-loop diuretics.
• Hypotensive/hypoperfusion: Cardiogenic shock.
  • Minority of patients.
  • Inotropes (dobutamine, milrinone) +/- vasopressors (norepinephrine).
  • Percutaneous Coronary Intervention if STEMI.
  • Following stabilization: loop diuretics +/- non-loop diuretics.

3. Hypovolemia

• Rare – overdiuresed/poor intake.
• Judicious fluid boluses.

4. Treat underlying cause

• ACS (revascularization recommended).
• Valvular disease.
• Pulmonary embolism.
• Infection (eg. pneumonia, endocarditis, sepsis).
• Arrhythmia.

Treatment Specifics

• Diuretics
  • Loop diuretics:
    • Chronic diuretic therapy: IV furosemide at 1-2 times usual daily PO dose, repeat in 2-3 hours if needed.
    • Diuretic naïve: IV Furosemide 20-40mg 2-3 times daily.
      • 20-80mg 2-3 times daily if eGFR<60mL/min.
    • Maximum = Furosemide 600mg/day.
  • Consider adding metolazone 2.5-5mg PO once daily (Increase to 10mg and max 20 mg daily) or Spironolactone 25-100mg PO once daily.
• Vasodilators
  • In hypertensive patients consider as initial therapy before diuretics.
  • Contraindicated if systolic <100mmHg and use with caution in those with significant aortic/mitral stenosis.
  • Nitroglycerin:
    • Contraindicated with recent (< 24H) PDE5 inhibitor use (unless chronically on Sildenafil for pulmonary hypertension).
    • IV nitroglycerin 10 micrograms/min, increase up to 200 micrograms/min.
    • Sublingual spray can be used until IV therapy is established or if unavailable: 0.4-0.8mg sublingual every 3-5 minutes.
  • Isosorbide dinitrate, nitroprusside and nesiritide are rarely used alternatives.
• Ultrafiltration
  • Not routine. It may be used as a last resort for volume and symptom management in some centers.

Shock (Hypotension/Hypoperfusion) Management

• Monitoring
  • Echocardiogram or FAST ultrasound help guide treatment.
  • Invasive monitoring recommended.
  • If ACS present, consider Percutaneous Coronary Intervention (better than thrombolysis).
• Fluid bolus
  • Consider small bolus of saline or Ringer’s lactate (250-500mL over 15-30 minutes) if no overt sign of fluid overload.
• Inotropes
  • Not shown to improve long term outcomes.
  • Risk: arrhythmias and myocardial ischemia.
  • Only for euvolemic/hypervolemic patients.
  • Dobutamine 2-20 micrograms/kg/min.
    • Consider alternatives for patients on beta blockers.
  • Milrinone 25-75 micrograms/kg bolus over 10–20 minutes then 0.375-0.75 micrograms/kg/min.
    • Avoid in ischemic heart failure.
•  Vasopressors
  • Avoid unless systolic BP < 80mm Hg.
    • Norepinephrine: 0.2 to 1.0 micrograms/kg/min.
•  Mechanical Circulatory Support
  • Not responding to medical therapies.
  • IABP, ECMO, VAD – site specific.
• Diuretics
  • Following stabilization if fluid overloaded.

Atrial Fibrillation (more info)

• ~35% of AHF patients present with Atrial Fibrillation (AF).
• Cardioversion if hemodynamically unstable due to AF.
• AF may be causative, a consequence of or a bystander to the AHF
  • Alternate trigger – absence suggests AF is causative.
  • Duration of AF – newly discovered AF suggests it is causative/consequence.
  • Ventricular Rate – rate >120 suggests AF is causative/consequence.
• AF consequence of AHF:
  • Treatment of AHF is the priority.
•  AF causative of AHF:
  • First, evaluate for and treat any suspected causes of AF.
  • Then, rate control (amiodarone/digoxin) and consider rhythm control (amiodarone).
• Consider anticoagulation for all AF patients.

Additional Management Notes

• Morphine – NOT routinely used.
• Thromboembolism Prophylaxis – Consider at admission.

• CCU/ICU Admission Recommended
  • Intubation required or patient already intubated.
  • Ongoing respiratory distress: use of accessory muscles for breathing, respiratory rate >25/min, SpO2 <90% (on oxygen).
  • Hemodynamic instability (hypotension/hypoperfusion).
  • Heart rate <40 or >130 bpm.
• Most remaining patients still require hospital admission.
• Patients with pre-existing HF and mild symptoms, stable vitals and labwork without significant comorbidities may be discharged following a dose of diuretics.
  • Adjust oral therapy if needed.
  • Reinforce salt and fluid restrictions if needed.
  • Advise outpatient follow-up.

• Admission Decision Tool (MDCalc).

• Patients with cardiogenic shock should be rapidly transferred to a tertiary care center with the following:
  • 24/7 cardiac catheterization.
  • ICU with mechanical circulatory support.

1. Ponikowski, P., Voors, A. A., Anker, S. D., Bueno, H., Cleland, J. G., Coats, A. J., … & Jessup, M. (2016). 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. European journal of heart failure, 18(8), 891-975.

   
   

2. Ezekowitz, J. A., O’Meara, E., McDonald, M. A., Abrams, H., Chan, M., Ducharme, A., … & Howlett, J. G. (2017). 2017 Comprehensive update of the Canadian Cardiovascular Society guidelines for the management of heart failure. Canadian Journal of Cardiology, 33(11), 1342-1433.

   
   

3. Kuo, D. C., & Peacock, W. F. (2015). Diagnosing and managing acute heart failure in the emergency department. Clinical and experimental emergency medicine, 2(3), 141-149.

   
   

4. R Teerlink, J., Alburikan, K., Metra, M., & E Rodgers, J. (2015). Acute decompensated heart failure update. Current cardiology reviews, 11(1), 53-62.

   
   

5. Long, B., Koyfman, A., & Gottlieb, M. (2018). Management of heart failure in the emergency department setting: an evidence-based review of the literature. The Journal of emergency medicine, 55(5), 635-646.

   
   

6. Allen, L. A., & O’Connor, C. M. (2007). Management of acute decompensated heart failure. Cmaj, 176(6), 797-805.

   
   

7. Yusuf S. Acute exacerbation of congestive heart failure. BMJ Best Practice. Oct 2018.

   
   

8. Gorenek, B., Halvorsen, S., Kudaiberdieva, G., Bueno, H., Van Gelder, I. C., Lettino, M., … & Poess, J. (2020). Atrial fibrillation in acute heart failure: A position statement from the Acute Cardiovascular Care Association and European Heart Rhythm Association of the European Society of Cardiology. European Heart Journal: Acute Cardiovascular Care, 2048872619894255.