Key Points
- Stabilize ABCs; begin targeted evaluation without delaying life-saving therapy.
- Use system-specific risk tools to guide testing and disposition.
- Order high-yield tests first; escalate imaging when indicated.
- Start evidence-based initial therapy and reassess frequently.
Algorithm
- Primary survey and vitals; IV access and monitors.
- Focused history/physical; identify red flags and likely etiologies.
- Order system-appropriate labs and imaging (see Investigations).
- Initiate guideline-based empiric therapy (see Pharmacology).
- Reassess response; arrange consultation and definitive management.
Clinical Synopsis & Reasoning
For Acute Decompensated Heart Failure Ed, frame the differential by acuity and pathophysiology, then align diagnostics to the leading hypotheses. Prioritize stabilization while obtaining high‑yield studies such as EKG (Rhythm/ischemia), Troponin (Myocardial injury), CXR (Pulmonary edema/size), BMP/Mg2+ (Electrolytes/renal). Incorporate bedside imaging and targeted labs to define severity and identify complications; synthesize results with clinical trajectory to refine the working diagnosis and disposition needs.
Treatment Strategy & Disposition
Initiate disease‑directed therapy alongside supportive care, titrating to objective response. Pharmacologic options commonly include Aspirin, P2Y12 inhibitor, Heparin/LMWH, Beta-blocker. Use validated frameworks (e.g., Common Interventions) to guide escalation and site of care. Address precipitating factors, de‑escalate empiric therapies with data, and arrange follow‑up for monitoring and risk‑factor modification; admit patients with instability, high risk of deterioration, or needs for close monitoring.
Epidemiology / Risk Factors
- Atherosclerotic risk (HTN, DM, HLD, smoking)
- Age/family history of premature CAD
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| EKG | Rhythm/ischemia | ST-T changes/arrhythmia | Serial |
| Troponin | Myocardial injury | Dynamic rise/fall | Trend |
| CXR | Pulmonary edema/size | Cardiomegaly/edema | |
| BMP/Mg2+ | Electrolytes/renal | Derangements | |
| CBC/Coags | Bleeding risk | Abnormal/INR |
Common Interventions
| Intervention | Typical use |
|---|---|
| Noninvasive ventilation | Moderate–severe pulmonary edema |
| IV nitroglycerin | Hypertensive pulmonary edema |
| Loop diuretics | Volume overload |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Sacubitril/valsartan | ARNI (RAAS/Neprilysin) | Days | GDMT for HFrEF | Hyperkalemia, hypotension; ED use |
| SGLT2 inhibitor | Renal SGLT2 blockade | Days | HF benefit regardless of diabetes | Euglycemic DKA (rare), GU infections; ED use |
| Mineralocorticoid receptor antagonist | Aldosterone blockade | Days | Mortality and hospitalization reduction | Hyperkalemia; gynecomastia (spironolactone); ED use |
| Loop diuretic | Na-K-2Cl inhibition (ascending limb) | Hours | Decongestion | Electrolyte loss, AKI; ED use |
| Beta-blocker (carvedilol/metoprolol succinate) | β1 blockade | Weeks | Mortality benefit | Bradycardia; titrate slowly; ED use |
Prognosis / Complications
- Prognosis by ischemic burden/LV function
- Arrhythmias and HF are complications
Patient Education / Counseling
- Explain red flags and when to seek emergent care.
- Reinforce medication adherence and follow-up plan.
Notes
Check renal function and electrolytes frequently. Consider ultrafiltration only for refractory congestion after medical therapy.