Congestive Heart Failure Exacerbation Management

Aka: Congestive Heart Failure Exacerbation Management, Cardiogenic Shock, Acute Pulmonary Edema Management, Acute Pulmonary Edema, Cardiogenic Pulmonary Edema, Acute Decompensated Congestive Heart Failure, Acute Heart Failure, CHF Exacerbation Management

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II. Indications

  1. Acute Pulmonary Edema secondary to CHF exacerbation
    1. However, many of the stabilization strategies are effective in Non-Cardiogenic Pulmonary Edema

III. Epidemiology

  1. Heart Failure exacerbations account for 1 million hospitalizations/year
    1. Account for 80% of all ED based admissions
    2. Account for most of the $40 billion spent on Heart Failure annually
  2. Rehospitalization or death in up to one third of patients within 90 days of Heart Failure hospitalization
    1. As many as 25% of patients are re-admitted in the first month
    2. Medicare penalizes facilities for readmissions within 30 days
    3. Early follow-up after CHF admission is critical (see below)

IV. Pathophysiology

  1. Congestive Heart Failure results in decreased Stroke Volume and Cardiac Output
  2. Decreased renal perfusion results in volume retention
    1. However only 50% of Pulmonary Edema patients are volume overloaded
  3. Decreased organ perfusion also stimulates other compensatory mechanisms
    1. Norepinephrine release results in increased Blood Pressure and cadiac output
    2. Renin Angiotensin-Aldosterone stimulation results in salt retention and increased vascular tone
  4. Redistribution of fluids
    1. Acute blood release from Spleen can rapidly deploy up to 800 ml fluid which may accumulate in the lungs

V. History

  1. See Diastolic Dysfunction
  2. See Systolic Dysfunction

VI. Exam

  1. See Systolic Dysfunction
  2. Findings that may differentiate Cardiogenic Shock from other shock types
    1. Jugular Venous Pressure >8 cm
    2. Mottled and cold skin
    3. Pulmonary congestion
    4. Pulse Pressure Narrow

VII. Labs

  1. Complete Blood Count
    1. Evaluate for Anemia or underlying infection
  2. Comprehensive metabolic panel
    1. Correct Hypokalemia
    2. Consider empiric Magnesium Sulfate (especially if hypokalemic)
      1. Serum Magnesium level does not reflect true intracellular Magnesium depletion
  3. Troponin I
    1. Evaluate differential diagnosis for Acute Coronary Syndrome
    2. Troponin Is increased in many cases of Acute Heart Failure (and in most cases if High Sensitivity Troponin is used)
    3. Persistently elevated Troponin at Day 2 (compared with admission Troponin) is associated with a worse prognosis
  4. B-Type Natriuretic Peptide (BNP or nt-BNP)
    1. Most helpful for its Negative Predictive Value (CHF is less likely with a normal BNP)
    2. Typically over-utilized, and may add little to diagnosis not available with other findings
    3. May be useful when an established "dry" baseline has been set for comparison and for risk stratification
    4. History, Exam and Bedside Ultrasound are often more effective tools in CHF evaluation
    5. Trending does not offer benefit over usual care for inpatient CHF management
      1. Felker (2017) JAMA 318(8): 713-20 +PMID:28829876 [PubMed]

VIII. Diagnostics

  1. See Systolic Dysfunction
  2. Electrocardiogram
  3. Chest XRay
    1. See Chest XRay in Congestive Heart Failure
    2. Normal in 19% of Acute Heart Failure cases
    3. Excludes alternative diagnoses (e.g. Pneumonia)
  4. Bedside Ultrasound or Echocardiogram
    1. See Echocardiogram in CHF
    2. See Bedside Lung Ultrasound in Emergency (Blue Protocol)
    3. See Rapid Ultrasound in Shock (RUSH Exam)
    4. See Inferior Vena Cava Ultrasound for Volume Status
    5. Bilateral B-Line Artifacts on Lung Ultrasound may be a useful adjunct in diagnosis of Acute Heart Failure syndrome
  5. Cardiac Impedance (Impedance Cardiography)
    1. Noninvasive ICU monitoring devices (skin leads) that may be available in some Emergency Departments
    2. Estimates Cardiac Output, Stroke Volume and Peripheral Vascular Resistance
    3. May assist in distinguishing between Preload and Afterload problems, and systolic and Diastolic Dysfunction
  6. Central Venous Catheter
    1. Central Venous Oxyhemoglobin Saturation <60% consistent with Cardiogenic Shock

IX. Causes: Acute Reversible Causes of Cardiogenic Decompensated Shock

  1. See Systolic Heart Failure
  2. See Heart Failure Causes
  3. Acute Dysrhythmia (e.g. Atrial Fibrillation with Rapid Ventricular Rate, third degree AV Block)
  4. Acute Myocardial Infarction (or Unstable Angina) - responsible for up to 70% of cases
    1. Large anterior Myocardial Infarction (>40% of left ventricle involved)
    2. Right ventricular infarction with Right Heart Failure and secondary Left Heart Failure
    3. Papillary Muscle rupture (with secondary severe valvular insufficiency, acute Mitral Regurgitation)
    4. Free wall rupture with Cardiac Tamponade
    5. Acute Ventricular Septal Defect
  5. Acute valvular lesion (rare, but potentially catastrophic)
  6. Acute Viral Myocarditis (esp. young patients)
  7. Uncontrolled Hypertension (Hypertensive Crisis)
  8. Hypothyroidism
  9. Excess Intravenous Fluid administration
  10. Severe Pulmonary Hypertension
    1. Right Ventricular Failure
  11. Non-compliance is most common cause
    1. Noncompliance with chronic CHF medications
    2. Excess Dietary Sodium intake
  12. Medications that Exacerbate Heart Failure
    1. NSAIDs
    2. Glitazones
    3. Excess dosing of newly started medication (e.g. Calcium Channel Blocker, Beta Blocker)
  13. High output Heart Failure Causes
    1. Severe Anemia
    2. Hyperthyroidism
    3. Septic Shock

X. Differential Diagnosis: Acute Congestive Heart Failure Exacerbation

  1. See Dyspnea Causes
  2. See Pulmonary Edema
  3. COPD Exacerbation
    1. Most difficult to distinguish acutely as Dyspnea cause
    2. Initial treatment of both COPD and CHF concurrently if appear equally plausible
      1. Many emergency Dyspnea protocols advocate this approach
  4. Pneumonia
    1. Consider the use of Procalcitonin to exclude Pneumonia when the Chest XRay is non-diagnostic
  5. Acute Coronary Syndrome
  6. Pulmonary Embolism
  7. Pneumothorax
  8. Acute Renal Failure
  9. High Altitude Pulmonary Edema
  10. Medication induced Pulmonary Edema (Opiates, Naloxone)

XI. Precautions

  1. Cardiogenic Pulmonary Edema presents most commonly without Fluid Overload
    1. Management focus should be on fluid redistribution, not diuresis
    2. Even those who are Fluid Overloaded (e.g. missed Diuretics, Dialysis) stabilize with fluid redistribution
    3. Fluid redistribution is the key strategy for Acute Heart Failure
      1. Regardless of whether it is due to Systolic Dysfunction or Diastolic Dysfunction
  2. Approach to fluid redistribution
    1. Decrease Preload (Nitroglycerin, BIPAP or CPAP)
    2. Decrease Afterload (ACE Inhibitor)
  3. Identify and specifically treat Acute Pulmonary Edema due to non-Heart Failure cause
    1. Acute Coronary Syndrome
    2. Acute Renal Failure
    3. Arrhythmia (e.g. Atrial Fibrillation with Rapid Ventricular Rate)
    4. Acute valvular catastrophe (presents with new regurgitation murmur)
  4. Rapidly disposition patients with Cardiogenic Shock to an optimal cardiac care setting
    1. Large Myocardial Infarction affecting the left ventricle is the common cause of Cardiogenic Shock
    2. Emergency department is for acute stabilization, but not ideal for definitive Cardiogenic Shock management
    3. Involve early cardiology, cath lab, cardiothoracic surgery, intensivists to expedite disposition
    4. Aspirin and Unfractionated Heparin if suspected underlying Myocardial Infarction
      1. Defer Platelet ADP Receptor Antagonist (e.g. Plavix) to cardiology

XII. Medications: Preload Reduction

  1. Nitroglycerin (see above)
    1. Most rapid method to reduce Congestive Heart Failure symptoms
      1. Reduces both Afterload and most significantly Preload
      2. Appears safe in Acute Pulmonary Edema and severe Aortic Stenosis, but Exercise caution
        1. Claveau (2015) Ann Emerg Med 66(4):355-62 +PMID:26002298 [PubMed]
    2. High dose (hypertensive Acute Heart Failure)
      1. Clinician should remain at bedside during this phase of administration
      2. Start: 0.4 mg sublingual every 3-5 minutes
      3. Next: High dose Nitroglycerin Drip (50-150 mcg/min) IV
        1. Significantly higher dosing that the typical 0.3 to 0.5 mcg/kg/min (10-25 mcg/min) infusion
        2. Expert opinion recommends starting IV Nitroglycerin at 100-150 mcg/min
      4. Next: Taper to 10-20 mcg/min as Hypoxia and Pulmonary Edema improve
        1. Titrate in 50 mcg increments every 10-15 minutes
    3. Lower dose (normotensive Acute Heart Failure)
      1. Nitroglycerin Ointment (0.5 to 1 inch)
  2. BIPAP (or CPAP)
    1. Consider starting with higher pressures (e.g. 20/15) with 100% FIO2
    2. Reduces work of breathing and opens alveoli
    3. Increases intrathoracic pressure and decreases venous return
    4. Improves Dyspnea and may avert Endotracheal Intubation
    5. Consider Dexmedetomidine (Precedex) if difficulty tolerating BIPAP or CPAP
      1. Sedative without respiratory depression (similar to Ketamine)
      2. Alpha Adrenergic Central Agonist (similar to Clonidine)

XIII. Medications: Afterload Reduction

  1. ACE Inhibitor
    1. Enalapril (Enalaprilat, Vasotec) 1.25 mg IV over 5 minutes or Captopril 12.5 to 25 mg sublingual
    2. Single dose for acute Afterload reduction (onset of action within 15 minutes)
    3. Start after the Nitroglycerin is tapered to lower dose (10-20 mcg/min)
    4. No evidence for Angiotensin Receptor Blockers (ARB)
  2. Nicardipine
    1. Offers pure arterial vasodilation, but Hypotension may take some time to resolve after stopping
    2. Clevidipine offers similar activity as Nicardipine with more rapid resolution of Hypotension on stopping
      1. Not widely used due to very high cost, but may be considered once generic
  3. Fenoldopam
    1. Dopamine-1 Agonist (without Dopamine-2 or alpha effects)
    2. Vasodilates peripherally as well as at the Kidney and Spleen (thereby preserving Renal Function)
  4. Nitroglycerin (see above)
    1. Rapid onset of effect, easily titrated, and Hypotension resolves readily on stopping infusion

XIV. Medications: Furosemide (Lasix) or other Loop Diuretic

  1. Indications
    1. Administered after Preload and Afterload reduction as above, IF Fluid Overloaded
    2. Fewer than 50% of CHF patients have total body Fluid Overload
  2. Option 1: Not on Home Diuretics
    1. Furosemide (Lasix) 40 mg IV (if not on home Diuretic) OR
    2. Furosemide (Lasix) 0.5 to 1.0 mg/kg (40-80 mg) IV
    3. Higher doses may be needed in Chronic Renal Failure
  3. Option 2: On home Diuretics
    1. Calculate hospital Furosemide dose
      1. Total Dose = HOME-DOSE * MULTIPLIER
      2. Where HOME-DOSE is the total daily home dose
      3. Where MULTIPLIER is typically 1.5 (up to 2.5)
      4. Divide the total daily dose over the number of doses per day
    2. Furosemide (Lasix) at 1.5 times the home dose of Loop Diuretic (typical, safer)
      1. Patient taking 40 mg orally daily at home would be given 30 mg IV every 12 hours
    3. Furosemide (Lasix) at 2.5 times the home dose of Loop Diuretic (high dose, caution!)
      1. Patient taking 40 mg orally daily at home would be given 50 mg IV every 12 hours
      2. Exercise caution with higher dose multiplier due to increased risk of Acute Renal Failure
      3. Felker (2011) N Engl J Med 364(9): 797-805 [PubMed]
  4. Option 3: Peacock ED Observation Unit Protocol (see disposition below)
    1. Goal of 1 Liter output during an ED observation
    2. Give Furosemide as single IV bolus of DOUBLE the patient's daily oral dose (max 180 mg IV)
    3. May repeat as twice the initial IV dose if inadequate urine out at 2 hours
      1. Urine < 0.5 L for Serum Creatinine <2.5 mg/dl OR
      2. Urine <0.25 L for Serum Creatinine >2.5 mg/dl
    4. References
      1. Peacock (2002) Congest Heart Fail 8(2):68-73 [PubMed]
  5. Adjuncts
    1. Acetazolamide 500 mg IV daily (in combination with Loop Diuretic)
      1. Associated with more rapid diuresis than Loop Diuretics alone (NNT 9 for decongestion by day 3)
      2. Those taking SGLT2 Inhibitors were excluded from study
      3. Mullens (2022) N Engl J Med 387(13):1185-95 +PMID: 36027559 [PubMed]
  6. Precautions
    1. Diuretics have a delayed onset of action until Afterload decreases and renal perfusion increases
      1. Diuretics are typically ineffective until other measures (e.g. Bipap, Nitroglycerin) redistribute fluid
      2. Use other agents listed under Preload and Afterload reduction first
      3. Loop Diuretics may not be indicated in all Acute Heart Failure stabilization
    2. Newer recommendations are to use with caution and at lower doses (see precautions above)
      1. Increased risk of Acute Renal Failure, increased hospital stays and increased mortality
    3. Furosemide Continuous Infusion is not recommended
      1. Considered low efficacy compared with bolus dosing and higher risk of complication (e.g. Hypokalemia)
      2. Dosing (listed for historical reference)
        1. Bolus: 40-80 mg IV
        2. Maintainence: 5-40 mg/hour IV infusion

XV. Medications: Additional Measures for refractory cases

  1. Percutaneous Coronary Intervention
  2. Ultrafiltration, ECMO or Dialysis
    1. Indicated in end-stage renal disease and Fluid Overload
    2. Phlebotomy of 200-300 cc blood may temporize if Dialysis is delayed
      1. Eiser (1997) Clin Nephrol 47(1): 47-9 +PMID: 9021241 [PubMed]
  3. Endotracheal Intubation and Mechanical Ventilation
    1. Decreases work of breathing and provides PEEP
    2. Ensure adequate fluid volume prior to RSI
  4. Intra-aortic balloon pump
    1. Decrease left Ventricular Afterload, wall tension and myocardial oxygen demand
    2. Indications
      1. Primarily indicated in mechanical catastrophe (e.g. ruptured mitral valve)
      2. May also be used to bridge to definitive therapy (e.g. PCI)
  5. Thrombolytics (in STEMI with secondary Cardiogenic Shock)
    1. May be considered in Cardiogenic Shock from STEMI and prolonged transport to PCI (>1.5 hours)
    2. Less effective in left main and proximal LAD lesions, as well as compared with PCI in general

XVI. Medications: Agents to avoid

  1. Avoid Beta Blockers in acute decompensated Systolic Dysfunction
  2. Avoid Nesiritide (Natrecor)
    1. No longer recommended (previously considered in refractory cases)
  3. Avoid Morphine Sulfate
    1. Poor to no effect on Preload reduction
    2. Associated with increased rates of intubation, ICU length of stay and possibly mortality
  4. Benzodiazepines
    1. Use only with caution
  5. Nitroprusside
    1. Historically started with 0.1 to 0.3 mcg/kg/min IV and titrate up to effect
    2. Falling out of favor due to unpredictable and catastrophic effects on Blood Pressure
  6. Digoxin
    1. Avoid Digoxin in Acute Heart Failure (not effective)

XVII. Management: General

  1. Intravenous lines
    1. Often challenging in CHF exacerbations due to peripheral Vasoconstriction and body habitus (i.e. Obesity)
    2. Consider Intraosseous Access or if time allows, Ultrasound-guided Intravenous Access
  2. Oxygen
  3. Monitor
  4. Defibrillator
  5. Advanced Airway equipment

XVIII. Management: Hypertensive Acute Heart Failure

  1. Criteria
    1. Acute Heart Failure AND
    2. Systolic Blood Pressure >180 mmHg
  2. Background
    1. Hypertensive Acute Heart Failure is typically due to Diastolic Heart Failure
    2. SCAPE
      1. Sympathetic surge AND
      2. Crashing AND
      3. Pulmonary Edema
  3. Step 1: Acute Stabilization (Preload reduction)
    1. BIPAP (or CPAP)
      1. Most important single measure
      2. Initiate without delay
    2. Nitroglycerin (see above)
      1. Start
        1. Oral: 400 mcg sublingual every 3-5 minutes (30% Bioavailability, peaks over minutes) OR
        2. IV: 250-500 mcg bolus (drawn from Nitroglycerin Infusion bottle 200 or 400 mcg/ml)
      2. Next: High dose Nitroglycerin Drip (50-200 mcg/min) IV
        1. Note that this is very high dosing
        2. Much higher dose than typical 0.3 to 0.5 mcg/kg/min (10-25 mcg/min) infusion
        3. Expert opinion recommends starting IV Nitroglycerin at 150 mcg/min
        4. Monitor with automatic Blood Pressure monitor cycling at every 2-5 minutes
      3. Next: Taper to 10-20 mcg/min as Hypoxia and Pulmonary Edema improve
  4. Step 2: Afterload Reduction
    1. ACE Inhibitor
      1. Enalapril (Enalaprilat, Vasotec) 1.25 mg IV over 5 minutes or
      2. Captopril 12.5 to 25 mg sublingual
      3. Single dose for acute Afterload reduction (onset of action within 15 minutes)
      4. Start after the Nitroglycerin is tapered to lower dose (10-20 mcg/min)
    2. Other Afterload reduction (if ACE Inhibitor contraindicated)
      1. See Afterload reduction preparations as above
      2. Nicardipine or Clevidipine
      3. Fenoldopam
  5. Step 3: Consider Loop Diuretic
    1. See dosing in the preparations section above
  6. Step 4: Refractory Cases
    1. Consider Ultrafiltration or Dialysis
    2. Consider Dobutamine (if no shock)
      1. Start with 2.5 mcg/kg/min IV and titrate up to effect

XIX. Management: Normotensive Acute Heart Failure

  1. Criteria
    1. Acute Heart Failure AND
    2. Systolic Blood Pressure >90 or 100 mmHg AND Systolic Blood Pressure <180 mmHg
  2. Background
    1. Normotensive Acute Heart Failure is typically due to Systolic Heart Failure
    2. Contrast with hypertensive Acute Heart Failure which is typically due to Diastolic Heart Failure
  3. Step 1: Acute Stabilization
    1. BIPAP (or CPAP)
    2. Nitroglycerin Ointment (0.5 to 1 inch) if systolic Blood Pressure > 120 mmHg
  4. Step 2: Loop Diuretics
    1. See dosing in the preparations section above
  5. Precautions: Normotensive Cardiogenic Shock
    1. Background
      1. Represents <10% of Cardiogenic Shock cases (most are hypotensive Cardiogenic Shock, see below)
      2. End organ ischemia and dysfunction despite normotensive Heart Failure
      3. Occurs when systolic Blood Pressure (SBP) <30 mmHg below patient's normal baseline SBP
    2. Findings
      1. Tachycardia
      2. Altered Mental Status
      3. Narrow Pulse Pressure
      4. Increased Jugular Venous Pressure
      5. Prolonged Capillary Refill
      6. Increased serum lactate
      7. Increased Serum Creatinine
    3. Management
      1. Use serial bedside Echocardiogram to titrate management
      2. Start with low dose inotrope
        1. Dobutamine (preferred in renal dysfunction)
        2. Mirinone (typically limited to experienced intensivists)
      3. Hypotension (may occur with inotrope)
        1. Norepinephrine
        2. Vasopressin (if additional Vasopressor is needed with Norepinephrine)

XX. Management: Hypotensive Acute Heart Failure (Cardiogenic Shock)

  1. Criteria
    1. Acute Heart Failure AND
    2. Systolic Blood Pressure <90-100/60 mmHg
      1. Hypotension alone is NOT equivalent to shock
      2. Shock occurs from cellular or tissue ischemia (decreased Oxygen Delivery or excessive demand)
      3. Cardiogenic Shock may be hypotensive (>90% of cases) or normotensive (<10% of cases, see above)
  2. Step 1: Acute Stabilization
    1. BIPAP (or CPAP)
    2. Small fluid bolus (250 to 500 ml)
    3. Close evaluation and re-evaluation
  3. Step 2: Inotrope selection (if above measures fail) with MAP goal >65 mmHg
    1. Congestive Heart Failure exacerbation without acute Myocardial Infarction
      1. Start with Norepinephrine and titrate to target MAP
      2. Vasopressin may be considered If a second agent is needed
      3. Low dose Epinephrine 0.01 to 0.08 mcg/kg/min may be considered
        1. However, Epinephrine has alpha and beta effects that may provoke Myocardial Ischemia
    2. Myocardial Infarction (STEMI, NSTEMI or new LBBB)
      1. Involve cardiology, cath lab for PCI, cardiothoracic surgery early
      2. Dobutamine 2.5 mcg/kg/min IV and titrate up to effect
        1. Risk of increasing Myocardial Ischemia, vasodilation and Hypotension, Tachycardia
      3. Significant Fluid Replacement will be required in Right Ventricular Failure
        1. Repeat frequent Lung Exams
        2. IVC Ultrasound for Volume Status may not reflect left ventricle volume
        3. Avoid Dobutamine and other Vasopressors while patient is fluid responsive
      4. Add Norepinephrine if Hypotension persists
    3. Severe Mitral or Aortic Stenosis
      1. Avoid agents that cause Tachycardia (e.g. Epinephrine, Dopamine)
      2. Consider Phenylephrine, Vasopressin
    4. Severe Mitral or Aortic Regurgitation
      1. Tachycardia may be beneficial
      2. Norepinephrine or Dopamine may be used
  4. Step 3: Advanced acute interventions
    1. Intra-aortic balloon pump
    2. Ultrafiltration or Dialysis
  5. Precautions
    1. Cardiogenic Shock due to CHF is associated with a 30 day mortality >50%
    2. Patients may be hypotensive at baseline with end-stage Heart Failure (review clinic Blood Pressures)
    3. Consider differential diagnosis, especially Septic Shock
    4. Follow serial Bedside Ultrasounds with each intervention

XXI. Disposition: New diagnosis of Acute Heart Failure

  1. Precautions
    1. Admit most (if not all patients) with new CHF diagnosis for evaluation, management and education
    2. Dedicated CHF clinic, close interval follow-up may be appropriate in some patients
  2. High risk markers (used in protocols below)
    1. BUN>43 or Serum Creatinine >2.8 mg/dl
    2. Systolic Blood Pressure <115 mmHg
    3. Oxygen Saturation <93%
  3. Disposition based on BNP when the diagnosis is unclear (example protocol)
    1. BNP >1000 pg/ml
      1. Admit
      2. Consider ICU admission if high risk markers positive (see above)
    2. BNP 400-1000 pg/ml
      1. Admit if Troponin Increase or high risk markers (see above) or
      2. Consider observation unit
        1. Recent admission or
        2. Initial emergency department management does not return the patient to baseline
      3. Discharge patients not meeting criteria for admission or observation
        1. Especially if marginal change in BNP (e.g. <25% difference between now and last discharge BNP)
    3. BNP <400 pg/ml (IF despite the normal BNP, Heart Failure is still suspected)
      1. Admit if Troponin Increased, high risk markers positive (see above)
      2. Consider observation unit if initial emergency department management does not return the patient to baseline
    4. References
      1. Pang (2012) J Cardiac Fail 18(12): 900-3 [PubMed]

XXII. Disposition: Acute Decompensation of Chronic Heart Failure

  1. Estimate risk of adverse event
    1. See Ottawa Heart Failure Risk Score
    2. See Congestive Heart Failure Exacerbation Decision Rule
    3. Emergency Heart Failure Mortality Risk Grade for 7 Day Mortality (EHMRG7)
      1. https://www.mdcalc.com/calc/1755/emergency-heart-failure-mortality-risk-grade-ehmrg
    4. STRATIFY Decision Tool
      1. Collins (2015) JACC Heart Fail 3(10):737-47 +PMID: 26449993 [PubMed]
  2. Most cases will require hospitalization (observation or admission)
    1. Hospital length of stay in Acute Heart Failure is typically >4 days
  3. Discharge home indications (subset of lower risk patients with reliable follow-up)
    1. Patient is not hypoxic on room air (or baseline Supplemental Oxygen) at rest and ambulation
    2. Patient is able to comply with home management (medications, diet, follow-up)
    3. Reliable clinic follow-up (especially if dedicated CHF clinic available)

XXIII. Disposition: Emergency Department Observation Unit

  1. Indications
    1. Established Heart Failure AND
    2. Acute findings consistent with CHF exacerbation (esp. if clear exacerbation trigger)
      1. Symptoms: Orthopnea, Dyspnea, Lower Extremity Edema, weight gain
      2. Signs: JVD, pulmonary rales, elevated BNP, Pulmonary Edema on CXR
  2. Contraindications
    1. Systolic Blood Pressure >220 mmHg or <100 mmHg
    2. Respiratory Rate >25
    3. Heart Rate >130
    4. Fever
    5. Supplemental Oxygen to keep O2Sat >90% (unless chronically oxygen dependent)
    6. Electrocardiogram with ischemic changes
    7. Increased Troponin
    8. Significant renal insuffiicency (e.g. Serum Creatinine >3 mg/dl or BUN >40 mg/dl)
    9. Inability to follow-up
    10. New onset Congestive Heart Failure
  3. Diagnostics and Monitoring
    1. Telemetry
    2. Continuous Pulse Oximetry
    3. Vital Signs every 4 hours
    4. Intake and Output monitoring
    5. Serial Troponin and basic metabolic panel (e.g. chem8) every 6 hours
    6. Echocardiogram (if not recently done)
  4. Medications and diet
    1. No added salt
    2. ACE Inhibitor
    3. Consider Nitroglycerin (e.g. Nitroglycerin Ointment)
    4. Diuretics (see protocols as above)
  5. Education
    1. Heart Failure general education
    2. Dietary triggers (e.g. salt)
    3. Weight monitoring
    4. Home health visit
  6. Discharge goals
    1. Symptomatic improvement
    2. Reassuring Vital Signs
    3. Non-ischemic EKG
    4. Negative cardiac enzymes
    5. Normal Electrolytes
    6. Adequate diuresis (1 Liter net output, weight loss, decreased JVD)
    7. Asymptomatic on ambulation (no Light Headedness, Chest Pain, improved Dyspnea)
    8. Resting Heart Rate <100 bpm
    9. Systolic Blood Pressure >90 mmHg
    10. Oxygen Saturation >90% (unless chronically oxygen dependent)
  7. Discharge
    1. Medication prescriptions (e.g. ACE Inhibitor, Diuretics)
    2. Established outpatient follow-up
  8. References
    1. Davenport and Baugh (2018) Crit Dec Emerg Med 32(7): 15-24
    2. Peacock (2002) Congest Heart Fail 8(2):68-73 [PubMed]

XXIV. Disposition: Follow-up

  1. Efficacy
    1. Reduces emergency department visits and readmission rates in the first 30-90 days (see above)
    2. Status Quo: 25% of patients are re-admitted in the first month and 33% rehospitalized or die within first 90 days
  2. Telephone or email contact within 2 days of hospital discharge
    1. Review symptoms
    2. Remind patient to check daily weights and call if weight changes by more than 2-3 pounds
    3. Partner with patient for Medication Compliance
      1. Of the 10 medications CHF exacerbation patients take at discharge, only 50% of patients are compliant
      2. Review barriers to Medication Compliance (e.g. cost)
  3. Clinic follow-up within 7 days of hospital discharge
    1. History
      1. Review hospital course and discharge recommendations (consider contacting discharge hospitalist)
      2. Review medication list and pill bottles
      3. Establish dry weight or target weight
      4. Review symptoms since discharge (Orthopnea or PND, Dyspnea on exertion, Chest Pain)
    2. Labs (examples)
      1. Serum Creatinine
      2. Serum Potassium
    3. Management
      1. Adjust medications based on clinical status
        1. See Diastolic Dysfunction
        2. See Systolic Dysfunction
      2. Specific measures to consider
        1. Diuretic (e.g. Furosemide) often requires adjustment following hospitalization
        2. Consider titrating ACE Inhibitor (up to 20-40 mg daily) or Angiotensin Receptor Blocker
        3. Consider titrating Metoprolol Succinate (Toprol XL, up to 200 mg daily)
        4. Consider adding AldosteroneAgonist such as Spironolactone or Eplerenone (Inspra)
    4. Charges
      1. CPT 99496 (transitional care management)
  4. References
    1. (2016) Presc Lett 23(2): 7-8
    2. Donaho (2015) J Am Heart Assoc 23;4(12) +PMID:26702083 [PubMed]

XXV. Prognosis

  1. Scoring Systems
    1. Congestive Heart Failure Exacerbation Decision Rule
    2. Ottawa Heart Failure Risk Score
  2. Mortality: 20-70%
  3. Poor Prognostic Factors (higher mortality)
    1. Advanced age
    2. Prior Coronary Artery Bypass Graft
    3. Hemodynamically unstable on presentation (hypotensive Cardiogenic Shock, end organ hypoperfusion)
    4. Increased Serum Creatinine
    5. Myocardial Infarction other than inferior MI

XXVI. References

  1. (2021) Presc Lett 28(1): 3-4
  2. Herbert, Weingart, Mattu, Sacchetti and Orman in Herbert (2014) EM:Rap 14(8): 11-13
  3. Herbert, Weingart, Mattu, Sacchetti and Orman in Herbert (2014) EM:Rap 14(9): 14
  4. Long and Lentz in Herbert (2021) EM:Rap 21(7): 11-2
  5. Orman and Berg in Herbert (2015) EM:Rap 15(6): 14-5
  6. Pang (2014) Crit Dec Emerg Med 28(9): 9-17
  7. Ryan (2001) CMEA Internal Medicine Lecture, San Diego
  8. Swaminathan and Mallemat in Herbert (2016) EM:Rap 16(2): 3-5
  9. Swaminathan and Weingart in Herbert (2018) EM:Rap 18(12): 5-7
  10. Swaminathan and Mattu (2024) Vasoactives in Cardiogenic Shock, EM:Rap, 7/15/2024
  11. (2000) Circulation 102(suppl I):I-189 [PubMed]
  12. Bloom (2023) J Am Heart Assoc 12(15): e029787 +PMID: 37489740 [PubMed]
  13. Marik (2012) J Intensive Care Med 27(6): 343-53 +PMID:21616957 [PubMed]

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