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2025 PACUPrep BCCCP Preparatory Course Heart Failure Acute Decompensated Heart Failure in the ICU: Management and Transition

Lesson 12, Topic 6

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Acute Decompensated Heart Failure in the ICU: Management and Transition

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Recovery and Transition in Acute Decompensated Heart Failure

Objective

Develop a plan to facilitate patient recovery, mitigate long-term complications, and ensure a safe transition of care.

Learning Points:

Implement stepwise weaning protocols for inotropes and vasopressors once hemodynamics stabilize.
Convert from IV to enteral therapy safely, accounting for oral bioavailability and enteral access tubes.
Identify high-risk patients for post–intensive care syndrome (PICS) and apply the ABCDEF bundle with early mobilization.
Conduct comprehensive medication reconciliation and structured discharge counseling to prevent readmission.
Initiate ARNI after a 36-hour washout from ACE inhibitors (no washout from ARBs); start low and titrate to target over 2–4 weeks.
Launch rapid sequential GDMT (ARNI, SGLT2i, beta-blocker, MRA, statin) within 4 weeks to maximize survival benefit.
Resume or start beta-blockers once euvolemic and off inotropes for 24–48 hours, with cautious up-titration every 2 weeks.
Maintain device-specific anticoagulation targets: UFH for Impella (ACT 160–180 s) and VA-ECMO (aPTT 60–80 s); prophylaxis only for IABP.
Recognize mechanical complications (free wall rupture, VSD, papillary muscle rupture) early and stabilize with volume, pressors, and emergent imaging.

I. Weaning and De-escalation of Intensive Therapies

Prompt tapering of vasoactive support as hemodynamics normalize reduces complications and expedites recovery.

A. Inotrope Weaning Protocol

Criteria: Off maximal vasopressor dose for 24–48 hours; Mean Arterial Pressure (MAP) ≥ 65 mmHg; Cardiac Index (CI) > 2.2 L/min/m²; normalized lactate; no signs of hypoperfusion.
Taper: Reduce dose by 25–50% every 6–12 hours; monitor MAP, CI, urine output, and lactate closely.
Decision point: If lactate rises or hypotension develops, reassess volume status, consider re-escalation of support, or evaluate for advanced therapies.

Holistic Weaning Assessment +

Integrate clinical examination findings, laboratory values (especially lactate trends), and, if available, invasive hemodynamic data (e.g., from a pulmonary artery catheter) to guide inotrope weaning. This comprehensive approach helps avoid sudden hemodynamic collapse.

B. Vasopressor Tapering Protocol

Criteria: MAP ≥ 65 mmHg without inotropes, or on stable low-dose inotrope if used for cardiac output.
Norepinephrine Wean: Decrease infusion rate by 0.02–0.05 mcg/kg/min every 4–6 hours. Monitor end-organ perfusion (urine output, mental status, peripheral warmth) and lactate levels.

Prioritized Weaning Strategy +

When multiple vasoactive drugs are used, wean the agent posing the greatest risk first. This decision should be tailored to the patient’s specific profile (e.g., risk of arrhythmia with dobutamine vs. increased afterload with high-dose norepinephrine).

II. Transition from Intravenous to Enteral Medications

A structured switch from intravenous (IV) to oral (PO) medications signals restored gastrointestinal perfusion and is a key step towards discharge planning.

A. IV-to-Oral Conversion Protocol

Loop Diuretic Oral Bioavailability and Equivalencies
IV Diuretic	Equivalent PO Dose (Furosemide)	Equivalent PO Dose (Torsemide)	Notes
Furosemide 40 mg IV	Furosemide 80 mg PO	Torsemide 20 mg PO	Furosemide PO bioavailability ~50% (variable)
Bumetanide 1 mg IV	Bumetanide 1 mg PO	N/A (often given 1:1)	Bumetanide PO bioavailability ~80-100%

ACE Inhibitors/ARBs, Beta-Blockers: Convert to oral formulations once the patient is hemodynamically stable and euvolemic. Prefer agents with high and predictable oral bioavailability.

Diuretic Absorption +

Torsemide offers more predictable oral absorption (80-100%) compared to furosemide (10-90%, average ~50%), which can be particularly beneficial in patients with gut edema due to heart failure.

B. Enteral Access Tube Considerations

Administer liquid formulations or crushable tablets whenever possible. Avoid crushing extended-release (ER) or enteric-coated medications.
Be aware that jejunal administration may impair the absorption of certain drugs (e.g., furosemide); monitor clinical effect closely.
Prevent tube occlusion: flush the tube with water before and after each medication administration. Stagger medication administration from enteral feeds if interactions are a concern.

III. Sequential Initiation of Guideline-Directed Medical Therapy (GDMT)

Early, sequential introduction of all four key pillars of heart failure drug classes, ideally within 4 weeks of stabilization or by discharge, is associated with the greatest mortality reduction.

Guideline-Directed Medical Therapy (GDMT) for HFrEF
Drug Class	Mechanism & Key Agents	Typical Starting & Target Dose	Key Monitoring	Contraindications/Cautions
ARNI (Angiotensin Receptor-Neprilysin Inhibitor)	Sacubitril/Valsartan: Neprilysin inhibition + AT1 blockade → natriuresis, vasodilation.	Start: 24/26 mg or 49/51 mg BID. Target: 97/103 mg BID. Titrate q2-4 wks.	BP, K+, renal function, angioedema signs.	History of angioedema, symptomatic hypotension, pregnancy. 36h ACEi washout required.
SGLT2 Inhibitors	Dapagliflozin, Empagliflozin: Block renal SGLT2 → glycosuria, natriuresis, ↓preload/afterload.	10 mg QD. No titration needed.	Volume status, renal function, genital mycotic infections, euglycemic DKA (rare).	eGFR < 20-25 mL/min/1.73m², Type 1 DM (caution), history of DKA.
Beta-Blockers (Evidence-based)	Carvedilol, Metoprolol Succinate, Bisoprolol: β-receptor blockade → ↓HR, ↓O₂ demand, reverse remodeling.	Carvedilol: 3.125 mg BID → 25-50 mg BID. Metoprolol Succ: 12.5-25 mg QD → 200 mg QD. Bisoprolol: 1.25 mg QD → 10 mg QD. Double dose q2 wks.	HR, BP, HF symptoms, fatigue, dizziness.	Active decompensation, bradycardia (HR <50-55), 2nd/3rd degree AV block (without pacemaker), symptomatic hypotension, severe reactive airway disease.
MRAs (Mineralocorticoid Receptor Antagonists)	Spironolactone, Eplerenone: Aldosterone antagonism → ↓Na+ reabsorption, ↓K+ excretion, ↓fibrosis.	Spironolactone: 12.5-25 mg QD → Target 25-50 mg QD. Eplerenone: 25 mg QD → Target 50 mg QD. Titrate q2 wks.	K+, renal function, BP, gynecomastia (spironolactone).	Hyperkalemia (K+ >5.0 mEq/L), severe renal impairment (eGFR <30 mL/min/1.73m² or Cr >2.5 mg/dL).
Statins (for Ischemic Etiology)	Atorvastatin, Rosuvastatin: HMG-CoA reductase inhibition.	Atorvastatin 40-80 mg QD or Rosuvastatin 20-40 mg QD.	LFTs (baseline), CK (if myalgia).	Active liver disease, pregnancy.

ARNI Washout +

A strict 36-hour washout period is mandatory when switching from an ACE inhibitor to an ARNI (sacubitril/valsartan) to prevent potentially life-threatening angioedema. No washout period is needed when switching from an ARB.

Beta-Blocker Initiation +

Never initiate or up-titrate beta-blockers during active decompensation or while a patient is on inotropes. Wait until the patient is euvolemic and hemodynamically stable, typically off inotropes for 24-48 hours. Start low and go slow.

IV. Anticoagulation Management for Mechanical Support Devices

Device-specific anticoagulation targets are crucial to balance the risk of thrombosis against bleeding complications.

A. Unfractionated Heparin (UFH)

UFH Anticoagulation Targets for Mechanical Circulatory Support
Device	Target Parameter	Target Range	Monitoring Frequency
Impella®	Activated Clotting Time (ACT)	160–180 seconds (some newer protocols may vary)	Per institutional protocol, often q2-6h initially
Veno-Arterial ECMO (VA-ECMO)	Activated Partial Thromboplastin Time (aPTT)	60–80 seconds (or Anti-Xa 0.3-0.7 IU/mL)	Per institutional protocol, often q4-6h initially

UFH dosing is typically weight-based infusion, titrated to achieve laboratory targets. Monitor ACT, aPTT, or anti-Xa levels as appropriate. Contraindications include a history of Heparin-Induced Thrombocytopenia (HIT) and active, uncontrolled bleeding.

UFH Monitoring Nuances +

Unfractionated heparin allows for rapid adjustments due to its short half-life, but it requires frequent laboratory monitoring. Circuit consumption of heparin, especially in ECMO, can lead to variability in anticoagulation levels.

B. Intra-Aortic Balloon Pump (IABP) Anticoagulation

Generally, prophylactic dosing of anticoagulation (e.g., low-dose UFH or LMWH) is sufficient unless there is another indication for therapeutic anticoagulation (e.g., atrial fibrillation, mechanical valve).
Monitor closely for signs of bleeding and limb ischemia at the IABP access site.

V. Mitigation of Post-Intensive Care Syndrome (PICS)

Early, structured interventions can significantly reduce the incidence and severity of PICS-related morbidity, which encompasses cognitive, psychological, and physical impairments following critical illness.

A. Risk Identification for PICS

Patients at high risk for PICS include those with:

Prolonged mechanical ventilation (>48 hours)
Deep or prolonged sedation
Sepsis or ARDS
Pre-existing frailty, cognitive impairment, or psychiatric illness
Multiple organ dysfunction

B. The ABCDEF Bundle

Systematic implementation of the ABCDEF bundle has been shown to improve outcomes, including shorter ICU stays, less delirium, and reduced PICS.

Figure 1: The ABCDEF Bundle for ICU Liberation

A: Assess, Prevent, and Manage Pain

Regularly assess pain using validated scales; treat with multimodal analgesia, prioritizing non-opioids.

B: Both Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs)

Daily interruption of sedation to assess neurological status and readiness for extubation.

C: Choice of Analgesia and Sedation

Use light sedation targets; prefer non-benzodiazepine sedatives (e.g., propofol, dexmedetomidine) when possible.

D: Delirium: Assess, Prevent, and Manage

Regularly screen for delirium using validated tools (e.g., CAM-ICU); implement non-pharmacologic prevention strategies.

E: Early Mobility and Exercise

Implement structured mobility protocols, starting with passive range of motion and progressing as tolerated, even in ventilated patients.

F: Family Engagement and Empowerment

Involve family in care, provide regular updates, and support their presence at the bedside.

Bundle Impact +

Consistent and full implementation of the ABCDEF bundle is associated with shorter ICU and hospital stays, lower incidence and duration of delirium, and reduced mortality.

C. Early Mobilization Strategies

Initiate Physical Therapy (PT) and Occupational Therapy (OT) protocols as early as feasible, even during mechanical ventilation if the patient is stable.
Minimize sedation to facilitate patient participation in mobilization activities.
Ensure adequate staff training, appropriate safety checks (e.g., hemodynamic stability, airway security), and allocation of resources (e.g., lifts, walkers).

VI. Comprehensive Medication Reconciliation and Discharge Counseling

Meticulous medication reconciliation and structured patient education are vital to prevent medication errors and reduce hospital readmissions.

A. Reconciliation Process

Systematically compare the patient’s pre-admission medication list, medications administered during the ICU stay, and the proposed discharge medication list.
Identify and resolve any discrepancies, duplications, omissions, or changes in dosing/frequency. Document reasons for all changes.

B. Patient and Caregiver Education

Provide clear, class-specific counseling on the indication, dosing schedule, common side effects, and important warnings for each discharge medication.
Utilize “teach-back” methods to ensure understanding.
Recommend adherence aids such as pillboxes, medication calendars, or smartphone reminder applications.

C. Handoff Communication and Follow-up

Provide the patient and their outpatient providers with a detailed written summary of medication changes, pending laboratory tests, and follow-up appointments.
Schedule a post-discharge follow-up appointment, ideally within 7 days of discharge, particularly for high-risk heart failure patients.
Proactively address potential barriers to adherence, such as medication cost, access issues, and health literacy.

Early Follow-Up Impact +

Early outpatient follow-up (within 7-14 days of discharge) for patients hospitalized with heart failure is strongly linked to lower rates of readmission and improved outcomes.

VII. Recognition and Initial Management of Structural Complications

Rapid diagnosis and stabilization of mechanical complications of acute myocardial infarction (e.g., free wall rupture, ventricular septal defect, papillary muscle rupture) are lifesaving.

A. Mechanical Ruptures (Free Wall, VSD, Papillary Muscle)

Clinical Signs: Sudden onset of severe hypotension, new harsh holosystolic murmur (VSD, papillary muscle rupture), signs of cardiac tamponade (free wall rupture), electromechanical dissociation.
Diagnostics: Emergent bedside echocardiography is the primary diagnostic tool. Computed tomography (CT) may be used if echocardiography is inconclusive or unavailable.
Initial Stabilization:
- Optimize volume status (often requires volume resuscitation, but cautiously if RV failure suspected).
- Initiate vasopressors (e.g., norepinephrine) to maintain perfusion.
- Afterload reduction (e.g., nitroprusside, IABP) may be beneficial in VSD or acute MR if SBP allows.
- Urgent cardiology and cardiothoracic surgery consultation is mandatory.

POCUS for Structural Diagnosis +

Point-of-care ultrasound (POCUS) performed by a trained clinician is the cornerstone for rapid, acute diagnosis of mechanical structural complications at the bedside, enabling timely intervention.

B. Mechanical Circulatory Support (MCS) for Structural Lesions

Device Choice: Selection of MCS (e.g., IABP, Impella, VA-ECMO) depends on the specific lesion, hemodynamic profile, and institutional expertise.
- IABP: Can reduce afterload and improve coronary perfusion; useful in acute MR or VSD.
- Impella: Provides direct LV unloading; beneficial in severe LV dysfunction.
- VA-ECMO: Offers full cardiopulmonary support; indicated for refractory shock or cardiac arrest.
Purpose: MCS is typically used as a bridge to definitive surgical repair or, in some cases, cardiac transplantation.
Follow device-specific anticoagulation protocols as outlined in Section IV.

MCS Guided by Hemodynamics +

Early selection and initiation of appropriate mechanical circulatory support, guided by the patient’s specific hemodynamic profile and the nature of the structural lesion, can improve survival in these critically ill patients.

References

Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. Circulation. 2022;145(18):e895–e1032.
Sinha SS, Morrow DA, Kapur NK, et al. ACC Expert Consensus on Cardiogenic Shock Management. J Am Coll Cardiol. 2025;85(16):1618–1641.
Randhawa VK, Al-Fares A, Tong MZY, et al. A Pragmatic Approach to Weaning Temporary Mechanical Circulatory Support. JACC Heart Fail. 2021;9(9):664–673.
Lim HS, Gonzalez-Costello J, Belohlavek J, et al. Hemodynamic Management of Cardiogenic Shock in the ICU. J Heart Lung Transplant. 2024;43:1059–1073.
Kadosh BS, Berg DD, Bohula EA, et al. Pulmonary Artery Catheter Use and Mortality in the CICU. JACC Heart Fail. 2023;11(11):903–914.
Polyzogopoulou E, Bezati S, Karamasis G, et al. Early Recognition and Risk Stratification in Cardiogenic Shock. J Clin Med. 2023;12(8):2643.
Devlin JW, Skrobik Y, Gélinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018;46(9):e825-e873. (Reference for ABCDEF bundle)
Maddox TM, Januzzi JL Jr, Allen LA, et al. 2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction. J Am Coll Cardiol. 2021;77(6):772-810. (Reference for GDMT sequencing)

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