2025 PACUPrep BCCCP Preparatory Course Heart Failure Vasoactive Agent Selection and Titration in Acute Decompensated Heart Failure
Supportive Care & Hemodynamic Monitoring in ADHF

Supportive Care Measures and Hemodynamic Monitoring in Acute Decompensated Heart Failure

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Objective

Recommend appropriate supportive care and monitoring to manage complications associated with acute decompensated heart failure and its treatment.

1. Respiratory Support in ADHF

Noninvasive and invasive ventilation rapidly improve oxygenation but exert distinct hemodynamic effects that require vigilant monitoring in acute decompensated heart failure (ADHF).

A. Noninvasive Ventilation (NIV)

  • Indications: Acute pulmonary edema with intact airway reflexes and stable mental status.
  • Modes & Settings:
    • CPAP 5–10 cm H₂O to reduce preload/afterload.
    • BiPAP inspiratory 10–15 cm H₂O / expiratory 5–10 cm H₂O for hypercapnia or acidosis.
  • Monitoring: Respiratory rate, SpO₂, blood pressure (BP), mental status, and signs of aspiration or right ventricular (RV) compromise.
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Use NIV early to avert intubation in cooperative, hemodynamically stable patients.

B. Mechanical Ventilation

  • Indications: Refractory hypoxemia, respiratory fatigue, altered mental status, high aspiration risk.
  • Ventilator Strategy: Low tidal volume (6–8 mL/kg ideal body weight) and initial PEEP 5 cm H₂O, titrated to oxygenation targets.
  • Hemodynamic Effects: Increased intrathoracic pressure decreases venous return; high PEEP may worsen RV afterload.
  • Weaning: Daily sedation interruptions and spontaneous breathing trials when stable.
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Balance PEEP for oxygenation against preload reduction—especially in preload‐dependent or RV‐failure patients.

2. ICU‐Related Complication Prevention

Prophylaxis protocols for VTE, stress ulcers, and infections reduce morbidity and mortality in critically ill ADHF patients.

A. Venous Thromboembolism (VTE) Prophylaxis

  • Unfractionated heparin (UFH) 5,000 U SC q8–12h if eGFR <30 mL/min/1.73 m²; Low-molecular-weight heparin (LMWH) (e.g., enoxaparin 40 mg SC daily) if renal function permits.
  • Mechanical: Intermittent pneumatic compression when bleeding risk is high.
  • Monitoring: Signs of bleeding, platelet count, and anti-Xa levels (especially in extremes of weight or renal dysfunction).

B. Stress Ulcer Prophylaxis

  • Indications: Mechanical ventilation >48 h, coagulopathy (INR >1.5, platelets <50 × 10³/µL), history of GI bleeding.
  • Agents: Proton pump inhibitor (PPI) (e.g., pantoprazole 40 mg IV daily) preferred; H₂-receptor antagonist (H₂RA) if C. difficile or pneumonia risk is a concern.
  • Discontinue when risk factors resolve.

C. Infection Control

  • Hand hygiene, contact precautions, central‐line insertion/maintenance bundles.
  • Ventilator-associated pneumonia (VAP) prevention: head‐of‐bed elevation 30–45°, daily sedation vacations, oral chlorhexidine care.
  • Antimicrobial stewardship: narrow based on cultures, de‐escalate promptly.
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Strict adherence to ICU prevention bundles reduces nosocomial infections and ICU length of stay.

3. Management of Iatrogenic Complications

Early detection and correction of therapy‐related electrolyte and rhythm disturbances prevent adverse events.

A. Diuretic‐Induced Electrolyte Imbalances

  • Monitor: Daily basic metabolic panel (BMP), renal function.
  • Replacement Targets: Potassium 4.0–4.5 mEq/L, Magnesium >2.0 mg/dL.
  • Adjust Diuretics: Reduce loop diuretic dose, consider adding a thiazide diuretic if resistant, and avoid over-diuresis to prevent hypotension or acute kidney injury (AKI).

B. Inotrope‐Related Arrhythmias

  • Continuous telemetry for arrhythmia detection.
  • Dose reduction or switch agent if ventricular ectopy or tachycardia occurs.
  • Treatment: Amiodarone or lidocaine; consider temporary pacing for bradyarrhythmias or heart block.

C. Acute Arrhythmias in ADHF

  • Ventricular Tachycardia/Fibrillation (VT/VF): ACLS algorithm with early defibrillation; amiodarone infusion for refractory cases.
  • New‐Onset Atrial Fibrillation (AF): Rate control (beta blockers or amiodarone); consider cardioversion if unstable; initiate anticoagulation once bleeding risk is acceptable.
  • Bradyarrhythmias: Atropine 0.5 mg IV q3–5 min up to 3 mg or transcutaneous pacing; escalate to transvenous pacing if needed.
Pearl Icon A shield with an exclamation mark, indicating a clinical pearl. Clinical Pearl

Maintain electrolytes in the upper normal range during inotrope infusions to minimize arrhythmia risk.

4. Multidisciplinary Goals‐of‐Care Conversations

Structured, early discussions ensure alignment of high‐burden therapies with patient values in refractory shock.

A. Identifying Candidates for High‐Burden Therapies

  • Indications: Persistent shock despite maximal medical support, pH <7.2, lactate >4 mmol/L.
  • Evaluate: Frailty, comorbidities, neurologic status, recovery potential.

B. Communication Frameworks

  • Use structured protocols (e.g., SPIKES) for delivering bad news and prognosis.
  • Engage palliative care early for symptom management and advance directive planning.
  • Document goals and revisit as clinical status evolves.
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Early goals‐of‐care conversations reduce nonbeneficial interventions and improve patient/family satisfaction.

5. Hemodynamic Monitoring and Pharmacotherapy

Invasive monitoring guides precise vasoactive and inotropic titration, timing of mechanical circulatory support (MCS), and transition to chronic therapy.

A. Arterial Line Utilization

  • Indications: Need for continuous BP monitoring, frequent arterial blood gases (ABGs), vasoactive drug titration.
  • Maintenance: Zero transducer at the level of the right atrium, check waveform for dampening, and perform regular site inspections.
  • Complications: Thrombosis, infection, hematoma.

B. Hemodynamic Targets

Table 1: Hemodynamic Targets in ADHF Management
Parameter Target Value
Mean Arterial Pressure (MAP) ≥65 mmHg
Cardiac Index (CI) ≥2.2 L/min/m²
Central Venous Oxygen Saturation (SvO₂) ≥65%
Lactate Clearance ≥10% per hour

C. Vasodilator Therapy

Table 2: Vasodilator Therapy in ADHF
Drug Mechanism Dosing Key Monitoring / Considerations
Nitroglycerin Venodilation > arterial dilation; reduces preload Start 5–10 mcg/min IV; titrate for dyspnea relief, maintain SBP ≥90–100 mmHg SBP, heart rate, tolerance (tachyphylaxis may occur after 48 hours)
Nitroprusside Balanced arterial and venous dilation; reduces afterload and preload Start 0.25 mcg/kg/min IV; titrate to SBP 100–120 mmHg Continuous BP monitoring, acid‐base status, cyanide/thiocyanate metabolites if used >48 hours. Pitfall: hypotension, cyanide toxicity.

D. Inotropic Support

Table 3: Inotropic Support in ADHF
Drug Mechanism Dosing Indications / Key Monitoring
Dobutamine β₁ agonist; increases contractility and cardiac output (CO) 2.5–20 mcg/kg/min IV Use when SBP >90 mmHg. Monitor BP, arrhythmias, tachyphylaxis.
Milrinone Phosphodiesterase-3 (PDE3) inhibitor; inotrope + vasodilator, independent of β-receptors 0.125–0.75 mcg/kg/min IV; adjust for renal function Indications: SBP 70–90 mmHg or chronic β-blocker use. Monitor for hypotension, arrhythmias, renal function.

E. Timing of Mechanical Circulatory Support (MCS)

  • Trigger: Refractory shock (pH <7.2 or lactate >4 mmol/L) despite escalating vasopressors.
  • Use SCAI stage C as an optimal window for device implantation to potentially improve outcomes.

F. Volume and Afterload Optimization

  • Preload: Guided diuresis using CVP or IVC ultrasound, targeting euvolemia.
  • RV Failure: Consider inhaled nitric oxide (e.g., 20 ppm) or inhaled epoprostenol (e.g., 0.01–0.05 mcg/kg/min) to reduce RV afterload.
  • Avoid fluid boluses in RV dysfunction.

G. Transition and Weaning Strategies

  • Vasopressors/Inotropes: Titrate down by 10–20% every 2–4 hours as hemodynamic targets are met.
  • MCS Weaning: Reduce flow by 0.5–1 L/min increments, with invasive hemodynamic reassessment.
  • Initiate/up-titrate oral guideline-directed medical therapy (GDMT): beta blockers, ACEi/ARB/ARNI, MRA, SGLT2 inhibitors.

H. Mechanical Support Device Selection

Table 4: Mechanical Circulatory Support Device Selection
Device Typical Flow Support Key Features / Insertion
Intra-Aortic Balloon Pump (IABP) <1 L/min Minimal anticoagulation typically required. Augments diastolic pressure.
Impella 2.5 / CP 2.5–4.0 L/min Percutaneous access (femoral artery). Direct LV unloading.
Impella 5.0 / 5.5 5.0–5.5 L/min Surgical insertion (axillary or femoral artery). Higher LV unloading.
Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) >4 L/min (full support) Full cardiopulmonary support. Consider in biventricular failure or severe hypoxemia. Requires systemic anticoagulation.
Key Point Icon A lightbulb, indicating a key point or insight. Key Point

Select the least invasive device that achieves perfusion goals and reassess daily for de-escalation or escalation as needed.

References

  1. Sinha SS, Morrow DA, Kapur NK, et al. ACC Expert Consensus on evaluation and management of cardiogenic shock. J Am Coll Cardiol. 2025;85(16):1618–1641.
  2. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for heart failure management. Circulation. 2022;145(18):e895–e1032.
  3. van Diepen S, Katz JN, Albert NM, et al. Contemporary management of cardiogenic shock. Circulation. 2017;136:e232–e268.
  4. Alviar CL, Miller PE, McAreavey D, et al. Positive pressure ventilation in the cardiac ICU. J Am Coll Cardiol. 2018;72(13):1532–1553.
  5. Randhawa VK, Al-Fares A, Tong MZY, et al. Weaning temporary MCS: state-of-the-art. JACC Heart Fail. 2021;9(9):664–673.
  6. Felker GM, Lee KL, Bull DA, et al. Diuretic strategies in ADHF. N Engl J Med. 2011;364(9):797–805.
  7. Waksman R, Pahuja M, van Diepen S, et al. SHARC definitions for cardiogenic shock. Circulation. 2023;148:1113–1126.
  8. Tehrani BN, Truesdell AG, Sherwood MW, et al. Standardized team-based care for cardiogenic shock. J Am Coll Cardiol. 2019;73(13):1659–1669.
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