Differential diagnosis: Pulmonary embolism, acute asthma, pneumonia, noncardiogenic pulmonary edema (eg, adult respiratory distress syndrome), pericardial tamponade or constriction |
Symptoms and signs |
Acute dyspnea, orthopnea, tachypnea, tachycardia, and hypertension are common |
Hypotension reflects severe disease, and arrest may be imminent; assess for inadequate peripheral or end-organ perfusion |
Accessory muscles are often used to breathe |
Diffuse pulmonary crackles are common; wheezing (cardiac asthma) may be present |
S3 is a specific sign but may not be audible; elevated jugular venous pressure and/or peripheral edema may be present |
Diagnostic studies |
Obtain ECG: Look for evidence of ischemia, infarction, arrhythmia (eg, AF), and left ventricular hypertrophy. |
Obtain portable chest radiograph: Look for signs of pulmonary edema, cardiomegaly, alternative diagnoses (eg, pneumonia); normal radiograph does not rule out ADHF. |
Obtain: Complete blood count; cardiac troponin; electrolytes (Na+, K+, Cl–, HCO3–); BUN and creatinine; arterial blood gas (if severe respiratory distress); liver function tests; BNP or NT-proBNP if diagnosis is uncertain. |
Perform bedside echocardiography if the cardiac or valvular function is not known. |
Treatment |
Monitor oxygen saturation, vital signs, and cardiac rhythm. |
Provide supplemental oxygen if hypoxic (SpO2 <90%), place 2 IV catheters, and position patient upright. |
Provide NIV as needed, unless immediate intubation is required or NIV is otherwise contraindicated; have airway management equipment readily available; etomidate is a good induction agent for RSI in ADHF. |
Initiate diuretic therapy without delay to relieve congestion/fluid overload: |
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Search for cause of ADHF (including: acute coronary syndrome, hypertension, arrhythmia, acute aortic or mitral regurgitation, aortic dissection, sepsis, renal failure, anemia, or drugs) and treat appropriately. |
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For patients with adequate end-organ perfusion (eg, normal or elevated blood pressure) and signs of ADHF with fluid overload: |
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For patients with known systolic HF (eg, documented low ejection fraction) presenting with signs of severe ADHF and cardiogenic shock, discontinue chronic beta blocker therapy and: |
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For patients with known diastolic HF (ie, preserved systolic function) presenting with signs of severe ADHF and cardiogenic shock: |
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For patients whose cardiac status is unknown but present with signs of severe ADHF (ie, pulmonary edema) and hypotension or signs of shock: |
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