Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Oxygen and NIV; start IV nitroglycerin in hypertensive ADHF; give IV loop diuretics.
- Evaluate for ACS/arrhythmias; correct triggers; monitor urine output and electrolytes.
- Escalate to vasodilators/inotropes in shock or persistent symptoms; plan GDMT optimization at discharge.
Clinical Synopsis & Reasoning
Acute dyspnea with rales and frothy sputum indicates pulmonary edema. Provide high-flow oxygen and early noninvasive ventilation, give IV nitrates to reduce preload/afterload (especially in hypertensive ADHF), and administer loop diuretics; investigate triggers (ischemia, arrhythmia, dietary/medication nonadherence).
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/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, CXR, bedside ultrasound | Diagnosis | Pulmonary congestion, B-lines, pleural effusion | Supportive |
| ECG/troponin | Etiology | Ischemia/arrhythmia | Guides ACS workup |
| BMP, Mg2+, renal function | Safety | Diuretic dosing and monitoring | — |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Respiratory distress/hypoxemia despite NIV | Impending respiratory failure | Consider intubation; ICU |
| Hypertensive flash pulmonary edema | Afterload crisis | High-dose IV nitroglycerin; arterial line |
| Hypotension, AKI, or shock | Poor perfusion | Inotrope/vasopressor strategy; ICU |
| Refractory volume overload | Diuretic resistance | Add thiazide-type synergy; ultrafiltration |
| Troponin elevation/new ischemia | ACS overlap | Activate ACS pathway |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Nitroglycerin IV titration (start 20–40 µg/min; escalate) | Vasodilator | Minutes | Rapid symptom relief in hypertensive ADHF | Avoid in RV infarct or severe AS |
| Furosemide IV (1–2× home dose) | Diuretic | Hours | Decongestion | Monitor urine output/electrolytes |
| Noninvasive ventilation (BiPAP) | Ventilatory support | Immediate | Reduces intubation/mortality | Contraindications apply |
| Vasodilators/inotropes (selected) | Adjuncts | Minutes | Nitroprusside for severe HTN; dobutamine if low output | ICU monitoring |
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
- AHA/ACC heart failure guidelines for acute management — Link