Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets (hemodynamic, neurologic, respiratory) and reassess frequently.
- Plan definitive source control or reperfusion when indicated; document follow‑up and patient education.
Algorithm
- Assess perfusion/congestion; oxygen, nitrates, and noninvasive ventilation for acute pulmonary edema.
- Give IV loop diuretic (1–2× home dose); monitor urine output and spot diuretic response.
- Add vasodilators if hypertensive; escalate to inotropes if cold/hypoperfused.
- Consider sequential nephron blockade or ultrafiltration for diuretic resistance.
- Optimize chronic GDMT prior to discharge; arrange close follow-up.
Clinical Synopsis & Reasoning
Identify perfusion/congestion profile (wet/dry; warm/cold). Use IV loop diuretics (1–2× home dose), consider vasodilators in hypertensive pulmonary edema, and escalate to inotropes/ultrafiltration for diuretic resistance and hypoperfusion.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced or procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| BNP/NT-proBNP | Support diagnosis | Elevated | Trend limited utility acutely |
| CXR/POCUS | Pulmonary edema/IVC | Interstitial edema, B-lines | Guide volume |
| BMP, Mg | Renal/electrolyte status | AKI, hypoK/Mg | Monitor during diuresis |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Furosemide IV 40–80 mg (or 1–2× home dose) | Loop diuretic | Hours | Decongestion | Monitor urine output/renal |
| Nitroglycerin infusion | Venodilator | Minutes | Hypertensive pulmonary edema | Headache/hypotension |
| Nitroprusside (selected) | Balanced vasodilator | Immediate | Severe afterload excess | Toxicity risks |
| Dobutamine/Milrinone | Inotropes | Minutes | Low-output states | Arrhythmia/hypotension |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- 2022 AHA/ACC/HFSA Heart Failure Guideline — Link