II. Indications

  1. Acute Pulmonary Edema secondary to CHF exacerbation

III. Epidemiology

  1. Heart Failure exacerbations account for 1 million hospitalizations/year
    1. Account for 80% of all ED based admissions
    2. Account for most of the $40 billion spent on Heart Failure annually
  2. Rehospitalization or death in up to one third of patients within 90 days of Heart Failure hospitalization
    1. Medicare penalizes facilities for readmissions within 30 days

V. Exam

VI. Labs

  1. Complete Blood Count
    1. Evaluate for Anemia or underlying infection
  2. Comprehensive metabolic panel
    1. Correct Hypokalemia
    2. Consider empiric Magnesium Sulfate (especially if hypokalemic)
      1. Serum Magnesium level does not reflect true intracellular Magnesium depletion
  3. Troponin I
    1. Evaluate differential diagnosis for Acute Coronary Syndrome
    2. Troponin Is increased in many cases of Acute Heart Failure (and in most cases if high sensitivity Troponin Is used)
    3. Persistently elevated Troponin at Day 2 (compared with admission Troponin) is associated with a worse prognosis
  4. B-Type Natriuretic Peptide (BNP or nt-BNP)
    1. Most helpful for its Negative Predictive Value (CHF is less likely with a normal BNP)
    2. Typically over-utilized, and may add little to diagnosis not available with other findings
    3. May be useful when an established "dry" baseline has been set for comparison and for risk stratification

VII. Diagnostics

  1. See Systolic Dysfunction
  2. Electrocardiogram
  3. Chest XRay
    1. See Chest XRay in Congestive Heart Failure
    2. Normal in 19% of Acute Heart Failure cases
    3. Excludes alternative diagnoses (e.g. Pneumonia)
  4. Bedside Ultrasound or Echocardiogram
    1. See Echocardiogram in CHF
    2. See Bedside Lung Ultrasound in Emergency (Blue Protocol)
    3. See Rapid Ultrasound in Shock (RUSH Exam)
    4. See Inferior Vena Cava Ultrasound for Volume Status
  5. Cardiac Impedance (Impedance Cardiography)
    1. Noninvasive ICU monitoring devices (skin leads) that may be available in some Emergency Departments
    2. Estimates Cardiac Output, Stroke Volume and peripheral vascular resistance
    3. May assist in distinguishing between Preload and Afterload problems, and systolic and Diastolic Dysfunction

VIII. Causes: Acute reversible causes of decompensated shock

  1. See Systolic Heart Failure
  2. See Heart Failure Causes
  3. Acute dysrhythmia (e.g. Atrial Fibrillation with rapid ventricular rate)
  4. Acute Myocardial Infarction
    1. Large anterior Myocardial Infarction (>40% of left ventricle involved)
    2. Right ventricular infarction with right Heart Failure and secondary left Heart Failure
    3. Papillary muscle rupture (with secondary severe valvular insufficiency)
  5. Severe Anemia
  6. Acute valvular lesion (rare, but potentially catastrophic)
  7. Uncontrolled Hypertension
  8. Hyperthyroidism
  9. Medications (e.g. NSAIDs, Glitazones)
  10. Excess Intravenous Fluid administration
  11. Excess dietary Sodium intake

IX. Differential Diagnosis: Acute Congestive Heart Failure Exacerbation

  1. See Dyspnea Causes
  2. COPD Exacerbation
    1. Most difficult to distinguish acutely as Dyspnea cause
    2. Initial treatment of both COPD and CHF concurrently if appear equally plausible
      1. Many emergency Dyspnea protocols advocate this approach
  3. Pneumonia
    1. Consider the use of Procalcitonin to exclude Pneumonia when the Chest XRay is non-diagnostic
  4. Acute Coronary Syndrome
  5. Pulmonary Embolism
  6. Pneumothorax
  7. Acute Renal Failure

X. Precautions

  1. Cardiogenic pulmonary edema presents most commonly without Fluid Overload
    1. Management focus should be on fluid redistribution, not diuresis
    2. Even those who are Fluid Overloaded (e.g. missed Diuretics, Dialysis) stabilize with fluid redistribution
    3. Fluid redistribution is the key strategy for Acute Heart Failure
      1. Regardless of whether it is due to Systolic Dysfunction or Diastolic Dysfunction
  2. Approach to fluid redistribution
    1. Decrease Preload (Nitroglycerin, BIPAP or CPAP)
    2. Decrease Afterload (ACE Inhibitor)
  3. Identify and specifically treat acute pulmonary edema due to non-Heart Failure cause
    1. Acute Coronary Syndrome
    2. Acute Renal Failure
    3. Arrhythmia
    4. Acute valvular catastrophe (presents with new regurgitation murmur)
  4. Rapidly disposition patients with Cardiogenic Shock to an optimal cardiac care setting
    1. Large Myocardial Infarction affecting the left ventricle is the common cause of Cardiogenic Shock
    2. Emergency department is for acute stabilization, but not ideal for definitive Cardiogenic Shock management
    3. Involve early cardiology, cath lab, cardiothoracic surgery, intensivists to expedite disposition
    4. Aspirin and Unfractionated Heparin if suspected underlying Myocardial Infarction
      1. Defer Platelet ADP Receptor Antagonist (e.g. Plavix) to cardiology

XI. Preparations: Preload Reduction

  1. Nitroglycerin (see above)
    1. Most rapid method to reduce Congestive Heart Failure symptoms
      1. Reduces both Afterload and most significantly Preload
      2. Appears safe in acute pulmonary edema and severe Aortic Stenosis, but Exercise caution
        1. Claveau (2015) Ann Emerg Med 66(4):355-62 +PMID:26002298 [PubMed]
    2. High dose (hypertensive Acute Heart Failure)
      1. Start: 0.4 mg sublingual every 3-5 minutes
      2. Next: High dose Nitroglycerin Drip (50-150 mcg/min) IV
        1. Note that this is significantly higher dosing that the typical 0.3 to 0.5 mcg/kg/min (10-25 mcg/min) infusion
        2. Expert opinion recommends starting IV Nitroglycerin at 150 mcg/min
      3. Next: Taper to 10-20 mcg/min as Hypoxia and pulmonary edema improve
    3. Lower dose (normotensive Acute Heart Failure)
      1. Nitroglycerin Ointment (0.5 to 1 inch)
  2. BIPAP (or CPAP)
    1. Consider starting with higher pressures (e.g. 20/15) with 100% FIO2
    2. Reduces work of breathing and opens alveoli
    3. Increases intrathoracic pressure and decreases venous return
    4. Improves Dyspnea and may avert Endotracheal Intubation
    5. Consider Dexmedetomidine (Precedex) if difficulty tolerating BIPAP or CPAP
      1. Sedative without respiratory depression (similar to Ketamine)
      2. Alpha Adrenergic Central Agonist (similar to Clonidine)

XII. Preparations: Afterload Reduction

  1. ACE Inhibitor
    1. Enalapril (Enalaprilat, Vasotec) 1.25 mg IV over 5 minutes or
    2. Captopril 12.5 to 25 mg sublingual
    3. Single dose for acute Afterload reduction (onset of action within 15 minutes)
    4. Start after the Nitroglycerin is tapered to lower dose (10-20 mcg/min)
    5. No evidence for Angiotensin Receptor Blockers (ARB)
  2. Nicardipine
    1. Offers pure arterial vasodilation, but Hypotension may take some time to resolve after stopping
    2. Clevidipine offers similar activity as Nicardipine with more rapid resolution of Hypotension on stopping
      1. Not widely used due to very high cost, but may be considered once generic
  3. Fenoldopam
    1. Dopamine-1 Agonist (without Dopamine-2 or alpha effects)
    2. Vasodilates peripherally as well as at the Kidney and Spleen (thereby preserving Renal Function)
  4. Nitroglycerin (see above)
    1. Rapid onset of effect, easily titrated, and Hypotension resolves readily on stopping infusion

XIII. Preparations: Furosemide (Lasix) or other Loop Diuretic

  1. Option 1: Not on Home Diuretics
    1. Furosemide (Lasix) 40 mg IV (if not on home Diuretic) OR
    2. Furosemide (Lasix) 0.5 to 1.0 mg/kg (40-80 mg) IV
  2. Option 2: On home Diuretics
    1. Calculate hospital Furosemide dose
      1. Total Dose = HOME-DOSE * MULTIPLIER
      2. Where HOME-DOSE is the total daily home dose
      3. Where MULTIPLIER is typically 1.5 (up to 2.5)
      4. Divide the total daily dose over the number of doses per day
    2. Furosemide (Lasix) at 1.5 times the home dose of Loop Diuretic (typical, safer)
      1. Patient taking 40 mg orally daily at home would be given 30 mg IV every 12 hours
    3. Furosemide (Lasix) at 2.5 times the home dose of Loop Diuretic (high dose, caution!)
      1. Patient taking 40 mg orally daily at home would be given 50 mg IV every 12 hours
      2. Exercise caution with higher dose multiplier due to increased risk of Acute Renal Failure
      3. Felker (2011) N Engl J Med 364(9): 797-805 [PubMed]
  3. Precautions
    1. Diuretics have a delayed onset of action until Afterload decreases and renal perfusion increases
      1. Use other agents listed under Preload and Afterload reduction first
      2. Loop Diuretics may not be indicated in all Acute Heart Failure stabilization
    2. Newer recommendations are to use with caution and at lower doses (see precautions above)
      1. Increased risk of Acute Renal Failure, increased hospital stays and increased mortality
    3. Furosemide Continuous Infusion is not recommended
      1. Considered low efficacy
      2. Dosing (listed for historical reference)
        1. Bolus: 40-80 mg IV
        2. Maintainence: 5-40 mg/hour IV infusion

XIV. Preparations: Additional Measures for refractory cases

  1. Percutaneous Coronary Intervention
  2. Ultrafiltration, ECMO or Dialysis
  3. Endotracheal Intubation and Mechanical Ventilation
    1. Decreases work of breathing and provides PEEP
    2. Ensure adequate fluid volume prior to RSI
  4. Intra-aortic balloon pump
    1. Decrease left Ventricular Afterload, wall tension and myocardial oxygen demand
    2. Indications
      1. Primarily indicated in mechanical catastrophe (e.g. ruptured mitral valve)
      2. May also be used to bridge to definitive therapy (e.g. PCI)
  5. Thrombolytics (in STEMI with secondary Cardiogenic Shock)
    1. May be considered in Cardiogenic Shock from STEMI and prolonged transport to PCI (>1.5 hours)
    2. Less effective in left main and proximal LAD lesions, as well as compared with PCI in general

XV. Preparations: Agents to avoid

  1. Avoid Beta Blockers in acute decompensated Systolic Dysfunction
  2. Avoid Nesiritide (Natrecor)
    1. No longer recommended (previously considered in refractory cases)
  3. Avoid Morphine Sulfate
    1. Poor to no effect on Preload reduction
    2. Associated with increased rates of intubation, ICU length of stay and possibly mortality
  4. Benzodiazepines
    1. Use only with caution
  5. Nitroprusside
    1. Historically started with 0.1 to 0.3 mcg/kg/min IV and titrate up to effect
    2. Falling out of favor due to unpredictable and catastrophic effects on Blood Pressure
  6. Digoxin
    1. Avoid Digoxin in Acute Heart Failure (not effective)

XVI. Management: General

  1. Intravenous lines
    1. Often challenging in CHF exacerbations due to peripheral Vasoconstriction and body habitus (i.e. Obesity)
    2. Consider Intraosseous Access or if time allows, Ultrasound-guided Intravenous Access
  2. Oxygen
  3. Monitor
  4. Defibrillator
  5. Advanced Airway equipment

XVII. Management: Hypertensive Acute Heart Failure

  1. Criteria
    1. Acute Heart Failure AND
    2. Systolic Blood Pressure >180 mmHg
  2. Background
    1. Hypertensive Acute Heart Failure is typically due to Diastolic Heart Failure
    2. SCAPE
      1. Sympathetic surge AND
      2. Crashing AND
      3. Pulmonary Edema
  3. Step 1: Acute Stabilization (Preload reduction)
    1. BIPAP (or CPAP)
    2. Nitroglycerin (see above)
      1. Start: 0.4 mg sublingual every 3-5 minutes
      2. Next: High dose Nitroglycerin Drip (50-150 mcg/min) IV
        1. Note that this is very high dosing
        2. Much higher dose than typical 0.3 to 0.5 mcg/kg/min (10-25 mcg/min) infusion
        3. Expert opinion recommends starting IV Nitroglycerin at 150 mcg/min
      3. Next: Taper to 10-20 mcg/min as Hypoxia and pulmonary edema improve
  4. Step 2: Afterload Reduction
    1. ACE Inhibitor
      1. Enalapril (Enalaprilat, Vasotec) 1.25 mg IV over 5 minutes or
      2. Captopril 12.5 to 25 mg sublingual
      3. Single dose for acute Afterload reduction (onset of action within 15 minutes)
      4. Start after the Nitroglycerin is tapered to lower dose (10-20 mcg/min)
    2. Other Afterload reduction (if ACE Inhibitor contraindicated)
      1. See Afterload reduction preparations as above
      2. Nicardipine or Clevidipine
      3. Fenoldopam
  5. Step 3: Consider Loop Diuretic
    1. See dosing in the preparations section above
  6. Step 4: Refractory Cases
    1. Consider Ultrafiltration or Dialysis
    2. Consider Dobutamine (if no shock)
      1. Start with 2.5 mcg/kg/min IV and titrate up to effect

XVIII. Management: Normotensive Acute Heart Failure

  1. Criteria
    1. Acute Heart Failure AND
    2. Systolic Blood Pressure >90 or 100 mmHg AND
    3. Systolic Blood Pressure <180 mmHg
  2. Background
    1. Normotensive Acute Heart Failure is typically due to Systolic Heart Failure
    2. Contrast with hypertensive Acute Heart Failure which is typically due to Diastolic Heart Failure
  3. Step 1: Acute Stabilization
    1. BIPAP (or CPAP)
    2. Nitroglycerin Ointment (0.5 to 1 inch) if systolic Blood Pressure > 120 mmHg
  4. Step 2: Loop Diuretics
    1. See dosing in the preparations section above

XIX. Management: Hypotensive Acute Heart Failure (Cardiogenic Shock)

  1. Criteria
    1. Acute Heart Failure AND
    2. Systolic Blood Pressure <90 to 100 mmHg
  2. Step 1: Acute Stabilization
    1. BIPAP (or CPAP)
    2. Small fluid bolus (250 to 500 ml)
    3. Close evaluation and re-evaluation
  3. Step 2: Inotrope selection (if above measures fail)
    1. Congestive Heart Failure exacerbation without acute Myocardial Infarction
      1. Norepinephrine
    2. Myocardial Infarction
      1. Involve cardiology, cath lab, cardiothoracic surgery early
      2. Dobutamine 2.5 mcg/kg/min IV and titrate up to effect
        1. Risk of increasing Myocardial Ischemia, vasodilation and Hypotension, Tachycardia
      3. Significant Fluid Replacement will be required in right ventricular failure
        1. Repeat frequent Lung Exams
        2. IVC Ultrasound for Volume Status may not reflect left ventricle volume
        3. Avoid Dobutamine and other Vasopressors while patient is fluid responsive
      4. Add Norepinephrine if Hypotension persists
  4. Step 3: Advanced acute interventions
    1. Intra-aortic balloon pump
    2. Ultrafiltration or Dialysis
  5. Precautions
    1. Cardiogenic Shock due to CHF is associated with a 30 day mortality >50%
    2. Patients may be hypotensive at baseline with end-stage Heart Failure (review clinic Blood Pressures)

XX. Disposition: New diagnosis of Acute Heart Failure

  1. Precautions
    1. Admit most (if not all patients) with new CHF diagnosis for evaluation, management and education
    2. Dedicated CHF clinic, close interval follow-up may be appropriate in some patients
  2. High risk markers (used in protocols below)
    1. BUN>43 or Serum Creatinine >2.8 mg/dl
    2. Systolic Blood Pressure <115 mmHg
    3. Oxygen Saturation <93%
  3. Disposition based on BNP when the diagnosis is unclear (example protocol)
    1. BNP >1000 pg/ml
      1. Admit
      2. Consider ICU admission if high risk markers positive (see above)
    2. BNP 400-1000 pg/ml
      1. Admit if Troponin Increase or high risk markers (see above) or
      2. Consider observation unit
        1. Recent admission or
        2. Initial emergency department management does not return the patient to baseline
      3. Discharge patients not meeting criteria for admission or observation
        1. Especially if marginal change in BNP (e.g. <25% difference between now and last discharge BNP)
    3. BNP <400 pg/ml (IF despite the normal BNP, Heart Failure is still suspected)
      1. Admit if Troponin Increased, high risk markers positive (see above)
      2. Consider observation unit if initial emergency department management does not return the patient to baseline
    4. References
      1. Pang (2012) J Cardiac Fail 18(12): 900-3 [PubMed]

XXI. Disposition: Acute decompensation of chronic Heart Failure

  1. Estimate risk of adverse event
    1. See Ottawa Heart Failure Risk Score
    2. See Congestive Heart Failure Exacerbation Decision Rule
  2. Most cases will require hospitalization (observation or admission)
    1. Hospital length of stay in Acute Heart Failure is typically >4 days
  3. Discharge home indications (subset of lower risk patients with reliable follow-up)
    1. Patient is not hypoxic on room air (or baseline Supplemental Oxygen) at rest and ambulation
    2. Patient is able to comply with home management (medications, diet, follow-up)
    3. Reliable clinic follow-up (especially if dedicated CHF clinic available)

XXIII. References

  1. Herbert, Weingart, Mattu, Sacchetti and Orman in Herbert (2014) EM:Rap 14(8): 11-13
  2. Herbert, Weingart, Mattu, Sacchetti and Orman in Herbert (2014) EM:Rap 14(9): 14
  3. Orman and Berg in Herbert (2015) EM:Rap 15(6): 14-5
  4. Pang (2014) Crit Dec Emerg Med 28(9): 9-17
  5. Ryan (2001) CMEA Internal Medicine Lecture, San Diego
  6. (2000) Circulation 102(suppl I):I-189 [PubMed]

Images: Related links to external sites (from Bing)

Related Studies (from Trip Database) Open in New Window

Ontology: Shock, Cardiogenic (C0036980)

Definition (NCI_CDISC) Cardiogenic shock is defined as a sustained (greater than30 minutes) episode of systolic blood pressure less than90 mm Hg, and/or cardiac index less than2.2 L/min/m2 determined to be secondary to cardiac dysfunction, and/or the requirement for parenteral inotropic or vasopressor agents or mechanical support (e.g., Intra aortic balloon pump (IABP), extracorporeal circulation, ventricular assist devices) to maintain blood pressure and cardiac index above those specified levels.
Definition (NCI_FDA) Shock resulting from primary failure of the heart in its pumping function, as in myocardial infarction, severe cardiomyopathy, or mechanical obstruction or compression of the heart.
Definition (NCI) Shock resulting from primary failure of the heart in its pumping function, as in myocardial infarction, severe cardiomyopathy, or mechanical obstruction or compression of the heart.
Definition (CSP) shock reulting from the failure of the heart to maintain adequate output.
Definition (MSH) Shock resulting from diminution of cardiac output in heart disease.
Concepts Pathologic Function (T046)
MSH D012770
ICD9 785.51
ICD10 R57.0
SnomedCT 207027002, 158355003, 89138009
English Shock, Cardiogenic, SHOCK CARDIOGENIC, Heart shock, Cardiogenic Shock, [D]Cardiogenic shock (context-dependent category), [D]Cardiogenic shock, [D]Heart shock, cardiocirculatory collapse, cardiogenic shock, cardiogenic shock (diagnosis), Shock cardiogenic, Shock, Cardiogenic [Disease/Finding], heart shocking, shock cardiogenic, shock heart, heart shock, [D]Cardiogenic shock (situation), CARDIOGENIC SHOCK, SHOCK, CARDIOGENIC, Cardiogenic shock, Cardiogenic shock (disorder), cardiogenic; shock, shock; cardiogenic
Portuguese CHOQUE CARDIOGENICO, Choque cardiogénico, Choque Cardiogênico
Spanish SHOCK CARDIOGENICO, [D]choque cardiogénico (categoría dependiente del contexto), Choque Cardiogénico, [D]shock cardiogénico, [D]choque cardiogénico, [D]choque cardiogénico (situación), Shock Cardiogénico, choque cardiógeno (trastorno), choque cardiógeno, shock cardiógeno, Shock cardiogénico
Dutch shock cardiogeen, cardiogeen; shock, shock; cardiogeen, cardiogene shock, Cardiogene shock, Shock, cardiogene
French Choc cardiogène, CHOC CARDOGENIQUE, Choc cardiogénique
German Kardialer Schock, Kardiogener Schock, SCHOCK KARDIOGEN, kardiogener Schock, Schock, kardialer, Schock, kardiogener
Japanese 心原性ショック, シンゲンセイショック
Swedish Chock, kardiogen
Finnish Kardiogeeninen sokki
Russian SHOK KARDIOGENNYI, ШОК КАРДИОГЕННЫЙ
Czech Šok kardiogenní, Kardiogenní šok, kardiogenní šok, šok kardiogenní
Korean 심인성 쇼크
Polish Wstrząs kardiogenny
Hungarian Shock, cardiogen, Cardiogen shock
Norwegian Kardiogent sjokk
Italian Shock cardiogeno

Ontology: Acute congestive heart failure (C0264719)

Concepts Disease or Syndrome (T047)
SnomedCT 195109001, 10633002
English acute congestive heart failure, congestive heart failure acute, Acute congestive heart failure (diagnosis), Acute congestive heart failure, Acute congestive heart failure (disorder)
Spanish fallo cardíaco congestivo agudo, insuficiencia cardíaca congestiva aguda (trastorno), insuficiencia cardíaca congestiva aguda

Ontology: Acute cardiac pulmonary edema (C0398350)

Concepts Disease or Syndrome (T047)
SnomedCT 233704001, 281251000009108, 360371003
English acute cardiac pulmonary edema (diagnosis), acute cardiac pulmonary edema, cardiogenic pulmonary oedema, cardiogenic pulmonary edema, Acute cardiac pulmonary oedema (disorder), Cardiogenic pulmonary edema (disorder), Acute cardiac pulmonary edema, Acute cardiac pulmonary oedema, Cardiogenic pulmonary edema, Cardiogenic pulmonary oedema, Acute cardiac pulmonary edema (disorder), Acute cardiogenic pulmonary edema, Acute cardiogenic pulmonary oedema, Acute cardiac pulmonary oedema [Ambiguous]
Spanish edema agudo de pulmón de causa cardíaca, edema agudo de pulmón de causa cardíaca (trastorno), edema pulmonar agudo por causa cardíaca (trastorno), edema pulmonar agudo por causa cardíaca, edema pulmonar cardiogénico