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Pharmacologic Algorithm for Acute Decompensated Heart Failure

Abnormal cardiac enzymes +/ischemic ECG changes? Treat as AMI or ACS Consider cath/PCI Consider IABP

Suspected acute/decompensated heart failure Yes History & physical, O2 sat CXR/ECG CBC, Chemistry, ?blood gas Consider cardiac enzymes Yes

Yes

Respiratory Failure imminent? No

Yes

BiPAP/CPAP trial Endotracheal intubation If BP elevated, consider nitroglycerin, nitroprusside, nesiritide ICU admission

Inotropes Consider IABP Cath, PCI for suspected AMI/ACS Hold HTN meds, -blockers, ACE-I, ARB

Yes

Cardiogenic shock or symptomatic hypotension? Hypoperfusion Cool extremities Altered mental status

No

Consider noncardiac etiology

No

Decompensated Heart Failure Likely? Yes

Unsure

BNP elevated?

No

Consider noncardiac etiology

No

Severe AS, HCM, restrictive CM, constrictive pericarditis, or tamponade confirmed? Yes

Yes Yes ECHO Clinical suspicion of severe AS, HCM, restrictive CM, constrictive pericarditis, tamponade? Evidence of LV diastolic dysfunction? Yes Refer to Diastolic Heart Failure Pathway

No

No

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Obtain Cardiology Consult

History of LV systolic dysfunction? Yes

No ECHO

Evidence of LV systolic dysfunction?

D/C offending drugs Class I antiarrhythmics NSAIDS Calcium channel blockers Consider beta-blocker dose reduction Supplemental oxygen Consider anticoagulation Consider ECHO if suspicion of worsening pump, valve function.

Yes

Cautious hydration

Yes

Volume depleted?

No

Volume overloaded?

No Optimize SNS, RAAS antagonism

Yes Diuresis and Aggressive Na+ restriction (< 2 g/day) Consider d/c metformin, TZDs

Total daily oral dose > 160 mg furosemide or serum creatinine > 2 mg/dL?

No

Administer 1-2 times oral furosemide dose IV If diuretic nave, start with 40 mg IV furosemide

Yes

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Consider diuretic resistance IV bolus dose to max of 160 mg Consider continuous infusion (start at 0.1 mg/ kg/hr) after bolus Consider addition of metolazone or hydrochlorothiazide

Yes Urine output 400 mL and improved symptoms after 2 hrs?

Optimize diuretic and ACE-I (or ARB) dose. Initiate/uptitrate betablocker once euvolemic

No

Optimize diuretic and ACE-I (or ARB) dose Initiate / uptitrate beta-blocker once euvolemic

Yes

Urine output 400 mL and improved symptoms after 2 hrs?

Re-bolus with 2 times initial IV dose at least 2 hours after first bolus

No Urine output 400 mL and improved symptoms after 2 hrs? Obtain cardiology consult Initiate nesiritide 2 g / kg loading dose followed by continuous infusion of 0.01 g / kg / min

Yes

No

Consider diuretic resistance IV bolus dose to max of 160 mg Consider continuous infusion (start at 0.1 mg/ kg/hr) after bolus Consider metolazone or hydrochlorothiazide Nesiritide 2 g / kg loading dose followed by continuous infusion of 0.01 g / kg / min