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Clinical Presentation and Management 171
of Acute Heart Failure

The unsatisfactory results of most recently com- apy.Venous thromboembolism prophylaxis is indicat-
pleted large clinical trials in patients with acute HF ed in patients hospitalized with acute HF. Sodium re-
clearly suggest a need for change in the traditional striction is suggested in all patients with HF.
paradigm of diagnosis and treatment in this complex Vasopressin receptor antagonists (aquaretics )are a
clinical syndrome, and a need to segregate patient rarely required option for patients with volume over-
profiles for triaging treatment modalities
load with severe hyponatremia (ie, serum sodium ≤120
meq/L) despite fluid restriction.It is suggested gen-
TREATMENT OF ACUTE HEART FAILURE – erally to avoid opiate therapy in patients with ADHF.
FROM PATHOPHYSIOLOGY TO BEDSIDE Supplemental oxygen therapy and assisted ventila-
tion should be provided as needed to treat hypoxemia
INITIAL THERAPY (SpO2 <90 percent). Oxygen is not recommended as
Approach to general management — Patients present- routine therapy in patients without hypoxemia, as it
ing with acute dyspnea from acute decompensated may cause vasoconstriction and reduction in cardiac
heart failure (ADHF) should be rapidly assessed and output.
stabilized. The initial approach is similar in patients For patients requiring supplemental oxygen,initial
with ADHF whether caused by systolic or diastolic therapies are usually in the following order:
dysfunction. Initial measures include:
• Non-rebreather facemask delivering high-flow
• Airway assessment and continuous pulse oxim- percent oxygen
etry to assure adequate oxygenation and venti-
lation • If respiratory distress, respiratory acidosis,
and/or hypoxia persist on oxygen therapy, we
• Supplemental oxygen and ventilatory support recommend a trial of noninvasive ventilation
(noninvasive ventilation [NIV] or intubation) as (NIV) if emergent intubation is not indicated,
indicated
no contraindications to NIV exist , and person-
• Vital signs assessment with attention to hypo- nel with experience in NIV are available.This
tension or hypertension approach is supported by evidence from me-
ta-analyses and randomized trials in patients
• Continuous cardiac monitoring , securing intrave- with cardiogenic pulmonary edema, indicating
nous access ,head-up position
that NIV decreases the need for intubation
• Diuretic therapy and / or early vasodilator thera- and improves respiratory parameters, such as
py (for severe hypertension, acute mitral regurgi- dyspnea, hypercapnia, acidosis, and heart rate.
tation, or acute aortic regurgitation); later vasodi- NIV may be particularly beneficial in patients
lator use for refractory cases is discussed below. with hypercapnia.
• Urine output monitoring (perhaps with urethral • Patients with respiratory failure who fail to im-
catheter placement) prove with NIV (within one-half to two hours)
or do not tolerate or have contraindications
Following airway and oxygenation assessment and
management, initial therapy includes the initiation of to NIV should be electively intubated for con-
treatments aimed at rapidly correcting hemodynam- ventional mechanical ventilation with positive
ic and intravascular volume abnormalities. The main- end-expiratory pressure being often useful to
stay of therapy in the acute setting is diuretics for improve oxygenation.
volume overload. Early intravenous vasodilator thera- • Once initial therapy has begun, oxygen sup-
py is suggested in selected patients with ADHF who plementation can be titrated in order to keep
require a decrease in systemic vascular resistance the patient comfortable and arterial oxygen
and left ventricular afterload (eg, those with severe saturation consistently above 90 percent.
hypertension, acute mitral regurgitation, or acute Diuretics — Patients with ADHF and evidence of vol-
aortic regurgitation). The aggressiveness of diuretic ume overload, regardless of etiology, should be treat-
and vasodilator therapy depends on the patient’s he- ed with intravenous diuretics as part of their initial
modynamic and volume status. Patients with flash therapy . As noted in the 2013 ACC/AHA HF guide-
pulmonary edema due to hypertension, for instance, lines, patients admitted with significant fluid overload
require aggressive vasodilatory therapy. Patients with should receive diuretic therapy without delay in the
normotension and volume overload may be treated emergency department or outpatient clinic, as early
with diuretic therapy with or without vasodilator ther-
intervention may produce better outcomes . Rare ex-

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