acute decompensated heart failure

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first 15 minutes

1. ABCs — sit upright, supplemental O₂ if SpO₂ <90%
2. IV access, cardiac monitor, 12-lead ECG
3. rapid assessment: vitals (BP critical — drives entire approach), JVP, lung auscultation, peripheral perfusion
4. investigations: troponin, BNP/NT-proBNP, lytes, Cr, CBC, lactate, VBG, CXR, ECG
5. identify precipitants — treat immediately if found (see below)

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haemodynamic profiling — Nohria-Stevenson

	warm (adequate perfusion)	cold (hypoperfusion)
wet	warm & wet (most common ~65%) → diuretics ± vasodilators	cold & wet → inotropes + cautious diuretics
dry	warm & dry → reassess diagnosis, optimise GDMT	cold & dry → cautious volume challenge, inotropes

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precipitants — “FAILURES”

	Cause	Immediate action
F	forgot medications	restart GDMT
A	arrhythmia (AF most common), anaemia	rate/rhythm control; transfuse if Hb <70
I	ischaemia/infarction, infection	ACS pathway; antibiotics
L	lifestyle (Na⁺/fluid excess)	counsel; diurese
U	upregulation (pregnancy, thyrotoxicosis)	treat underlying
R	renal failure	assess cardiorenal syndrome
E	embolism (PE)	CT-PA if suspected
S	stenosis (aortic) / valvular emergency	urgent echo; surgical/interventional assessment

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management by profile

warm & wet — vasodilate + diurese (SBP >110)

Vasodilators — reduce preload and afterload; rapid symptom relief in flash pulmonary oedema:

Agent	Dose	Notes
NTG infusion	start 10–20 µg/min, titrate to BP	first-line if SBP >110; sublingual 0.4 mg q5min as bridge
NTG paste	1–2 inches topical	slower onset; useful if IV access delayed
nitroprusside	0.25–5 µg/kg/min	balanced vasodilator; use in hypertensive crisis + ADHF; requires arterial line; cyanide toxicity risk with prolonged use

Diuresis — see condensed algorithm below; full protocol in diuretic therapy in acute heart failure.

NIV — if respiratory distress despite initial measures:

• CPAP or BiPAP reduces intubation and improves symptoms — 3CPO (2008) showed no mortality benefit but reduced dyspnoea and need for intubation
• start CPAP 5–10 cmH₂O or BiPAP 10/5, titrate to work of breathing
• contraindications: unable to protect airway, vomiting, pneumothorax, SBP <85

warm & wet — diurese (SBP 90–110)

• IV loop diuretics as primary strategy
• avoid vasodilators if borderline BP
• hold/reduce non-essential antihypertensives to create “room” for GDMT

cold & wet — inotropes + cautious diuresis (SBP <90 or signs of hypoperfusion)

Agent	Mechanism	Role
dobutamine	β₁ agonist → ↑ inotropy, ↑ HR	first-line inotrope; start 2–5 µg/kg/min
milrinone	PDE3 inhibitor → ↑ inotropy + vasodilation	useful if on BB (BB-independent); risk of hypotension; avoid in ischaemic CM — OPTIME-CHF (2002)
norepinephrine	α₁ + β₁ → ↑ SVR + inotropy	if SBP <80 or vasodilatory shock component; preferred over dopamine — SOAP II (2010)
epinephrine	α + β agonist	refractory shock; high arrhythmia risk
levosimendan	calcium sensitiser	not available in Canada; used in Europe for acute-on-chronic HF

• add cautious loop diuretics once perfusion is restored
• early HF specialist / ICU involvement
• consider mechanical circulatory support (IABP, Impella, ECMO) if refractory

cold & dry — rare

• cautious 250 mL crystalloid bolus, reassess
• may need inotropes if no response
• consider RV failure (PE, RV infarct) — preload dependent

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condensed diuresis algorithm

For the full natriuresis-guided protocol, electrolyte management, and trial evidence → diuretic therapy in acute heart failure

Step	Action	Target
1. Start	IV furosemide: dose by GFR (eGFR >45: 80 mg; 30–45: 120 mg; <30: 160–200 mg); give q12h	—
2. Check 2h	spot urine Na⁺	>50 mmol/L
3. If inadequate	double dose or increase frequency	—
4. Check 6h	cumulative urine output	>150 mL/h
5. If still inadequate	add acetazolamide 500 mg IV (upfront prevention)	—
6. If established resistance	add metolazone 2.5–5 mg PO 30 min before loop	—
7. Rescue	KCl repletion for hypochloraemia → hypertonic saline if refractory	—

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oxygen and ventilation

SpO₂	Action
>94%	no supplemental O₂ (hyperoxia may increase SVR and worsen afterload)
90–94%	nasal prongs / simple mask
<90% or respiratory distress	NIV (CPAP/BiPAP)
failing NIV, exhaustion, unable to protect airway	intubation (use ketamine or etomidate — avoid propofol bolus in decompensated HF)

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ICU admission criteria

• cardiogenic shock or need for inotropes/vasopressors
• SBP <85 despite initial management
• respiratory failure requiring NIV or intubation
• acute mechanical complication (acute MR, VSD, free wall rupture)
• refractory arrhythmia
• acute coronary syndrome as precipitant requiring urgent intervention

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discharge checklist

Item	Detail
euvolaemia confirmed	stable weight on oral diuretics × 24–48h
GDMT optimised	all four pillars initiated or documented contraindication — STRONG-HF (2022)
oral diuretic dose set	double the effective IV dose for PO furosemide (50% bioavailability)
electrolytes stable	K⁺ >4.0, Mg²⁺ >0.8, Na⁺ >130
daily weight instructions	weigh same time each morning; call if gain >2 kg in 2 days
follow-up booked	1–2 weeks post-discharge for lytes, Cr, BP, GDMT titration
precipitant addressed	AF controlled, infection treated, adherence counselled
device eligibility flagged	if LVEF ≤35% — reassess after ≥3 months OMT
fluid / Na⁺ guidance	moderate Na⁺ restriction (<2000 mg/day); fluid restriction only if hyponatraemic
vaccination	influenza, COVID, pneumococcal if not up to date