Management of Acute Heart Failure during an Early Phase

Abstract

Acute heart failure (AHF), a global pandemic with high morbidity and mortality, exerts a considerable economic burden. AHF includes a broad spectrum of clinical presentations ranging from new-onset heart failure to cardiogenic shock. Key elements of the management rely on the clinical diagnosis confirmed on, both, increased natriuretic peptides and echocardiography, and on the prompt initiation of oxygen therapy, including non-invasive positive pressure ventilation, vasodilators, and diuretics. A care pathway is essential, specifically when an acute coronary syndrome is suspected or in the case of cardiogenic shock. Association or increasing doses of vasopressors despite an adequate volume status are markers of progression toward a refractory cardiogenic shock state. For the latter, mechanical circulatory support should be initiated early, optimally before the onset of renal or liver failure. Thus, a tertiary care center is recommended for the management of patients with AHF who require percutaneous coronary intervention or mechanical circulatory support. This narrative review provides multidisciplinary guidance for the management of AHF and cardiogenic shock from pre-hospital to intensive care unit/cardiac care unit, based on contemporary evidence and expert opinion.

Keywords: Cardiogenic shock; Emergency; Heart failure; Therapeutics.

Figure 1. Clinical profiles of patients with acute HF based on the presence/absence of congestion and/or hypoperfusion. Adapted from the 2016 ESC guidelines on acute and chronic HF. This approach was proposed by the analysis of Nohria et al. Frequencies of the groups are given according to this analysis.

ESC = European Society of Cardiology; HF = heart failure; MCS = mechanical circulatory support; sBP = systolic blood pressure.

Figure 2. Flowchart for vasodilator and diuretic use in acute heart failure. Of note, the “vascular type” usually has high sBP and preserved LVEF while the “cardiac type” presents normal sBP and reduced LVEF.

IV = intravenous; IVC = inferior vena cava; LVEF = left ventricular ejection fraction; sBP = systolic blood pressure.

Figure 3. Hospital management of patients with suspected acute heart failure.

For more detail on the medications for congestion, refer to Figure 2. ACS = acute coronary syndrome; AHF = acute heart failure; CATH LAB = cardiac catheterization laboratory; CCU = cardiac care unit; DCM = dilated cardiomyopathy; ECG = electrocardiogram; ICU = intensive care unit; MAP = mean arterial pressure; MCS = mechanical circulatory support; NIPPV = non-invasive positive pressure ventilation; RR = respiration rate; sBP = systolic blood pressure; SpO₂ = oxygen saturation; US = ultrasound; VSR = ventricular septal rupture.