Tips for Management of Acutely Decompensated Heart Failure

Educational Objectives

The goal of this program is to improve management of patients with decompensated heart failure (DHF). After hearing and assimilating this program, the clinician will be better able to:

1. Use lung ultrasonography to evaluate patients with suspected DHF.

Summary

Heart failure (HF): HF is a syndrome not a diagnosis; HF guidelines in Europe suggest assessing patients suspected of decompensated heart failure (DHF) phenotypically by evaluating perfusion status (eg, temperature of extremities, pulse pressure, mental status) and congestion (eg, presence of orthopnea, dyspnea on exertion, elevated jugular venous pressure, peripheral edema, ascites); congestion does not necessarily mean volume overload

Clinical presentation: the most common presentation is warm (adequate perfusion) and wet (congestion), which may be managed by diuretics and vasodilators for afterload reduction in severe cases; patients with a history of congestive heart failure (CHF) may present as warm and dry; clinical presentation of CHF is similar to that of DHF (differential diagnosis); a different underlying cause of symptoms should be considered for patients with this phenotype; cold and wet is a less common presentation and may indicate a more serious event; early diagnosis is important as patients may benefit from vasodilators and diuretics; inotropes may be needed in cases of low body temperature and inadequate perfusion; a cold and wet presentation is rare and indicates a severe case of DHF; patients are in cardiogenic shock and are often diagnosed at later stages; presentation is similar to that of sepsis which may cause confusion; management includes inotropes or mechanical circulatory support; advanced heart failure resources may be needed

Lung ultrasonography (US): lung US is recommended in patients with shortness of breath, hypoxia, and other symptoms of HF; lung US shows B lines in cases of pulmonary edema or congestion; use of lung US over chest x-ray and brain natriuretic peptide levels to diagnose suspected HF is supported by results of RCTs; elevating the gain is recommended to increase visibility of B lines on US

Sympathetic crashing acute pulmonary edema (SCAPE): presentation is typically dramatic; may be caused by a triggering event in patients with underlying cardiac dysfunction; a smaller trigger is required in patients with severe dysfunction; the presentation is driven by increasing sympathetic outflow which causes vasoconstriction and a rapid rise in afterload; a fluid shift into the lungs occurs; patients are not necessarily volume overloaded; early intervention is crucial; presentation includes rapid onset, shortness of breath, tachypnea, hypoxia, and hypertension; features of sympathetic activation are also present, eg, sweating, tachycardia, restlessness, B lines on US

Management of SCAPE: the mainstay of treatment is noninvasive ventilation which improves outcomes and reduces mortality; continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) should be started at low pressures and increased quickly as tolerated; afterload is managed with high-dose nitroglycerin; recent evidence suggests higher doses than normal of nitroglycerin may be used; the diagnosis should be reconsidered or other agents, eg, nicardipine, tried if high-dose nitroglycerin is ineffective

Readings

Authors/Task Force Members, McDonagh TA, Metra M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC. European Journal of Heart Failure. 2022; 24(1), 4–131. https://doi.org/10.1002/ejhf.2333; Chiu L, Jairam MP, Chow R, et al. Meta-analysis of point-of-care lung ultrasonography versus chest radiography in adults with symptoms of acute decompensated heart failure. The American Journal of Cardiology. 2022; 174, 89–95. https://doi.org/10.1016/j.amjcard.2022.03.022; Finfer S, Micallef S, Hammond N, et al. Balanced multielectrolyte solution versus saline in critically ill adults. The New England Journal of Medicine. 2022; 386(9), 815–826. https://doi.org/10.1056/nejmoa2114464; Gargani L, Volpicelli G. How I do it: Lung ultrasound. Cardiovascular Ultrasound. 2014; 12(1), 25. https://doi.org/10.1186/1476-7120-12-25; Houseman BS, Martinelli AN, Oliver WD, Devabhakthuni S, Mattu A. High-dose nitroglycerin infusion description of safety and efficacy in sympathetic crashing acute pulmonary edema: The HI-DOSE SCAPE study. Am J Emerg Med. 2023;63:74-78. Doi:10.1016/j.ajem.2022.10.018.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Mackenzie was recorded at Emergency Medicine Update 2023, held January 22-25, 2023, in Stowe, VT, and presented by the Larner College of Medicine at The University of Vermont. For information about upcoming CME activities from this presenter, please visit med.uvm.edu/cmie. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

EM410702

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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