CHF Exacerbations in the ED: Wet Lungs, Full Hearts

-Case-
A 72-year-old man with a history of HFrEF, CAD, and HTN presents to the ED with worsening shortness of breath – particularly on exertion – over the past 3 days. He has orthopnea, paroxysmal nocturnal dyspnea, and new bilateral lower extremity swelling. He’s tachypneic, hypertensive, and using accessory muscles. His O2 sat is 88% on room air. Bibasilar crackles and elevated JVP are noted on exam… 

-Evaluation-
CHF exacerbations occur when cardiac output fails to meet the body’s demands, leading to fluid overload. The most common causes include dietary indiscretion (salt or fluid) in the setting of existing poor ejection fraction, medication noncompliance, renal failure, arrhythmias, and ischemia.

Typical Presentation:

• Dyspnea, orthopnea, PND
• Peripheral edema, weight gain
• Fatigue, exercise intolerance
• Rales, S3, elevated JVP, peripheral congestion

Initial ED Workup:

• Vitals: pay attention to hypoxia, tachypnea, and blood pressure!
• Labs: BNP/NT-proBNP, troponin, CBC, electrolyte panel
• CXR: pulmonary vascular congestion, interstitial edema, cardiomegaly
• EKG: look for arrhythmias and signs of ischemia
• POCUS: you might find B-lines, a plethoric IVC, and decreased cardiac ejection fraction

-Management-

• Oxygen: supplemental O2 (especially if SpO2 <90%); consider BiPAP for moderate/severe respiratory distress or hypoxia
• Diuretics: IV furosemide is first-line; start with home dose equivalent or higher if the patient is compliant to their diuretics, or start low if the patient is diuretic-naïve
• Nitroglycerin: especially useful in hypertensive patients to reduce preload and afterload
• Vasodilators: consider if persistent hypertension despite nitrates
• Avoid aggressive fluid resuscitation! These patients are fluid-overloaded, not volume-depleted

-Fast Facts-

• CHF exacerbation is a clinical diagnosis, but supported by BNP, imaging, and ultrasound
• POCUS can often make the diagnosis faster than chest X-ray
• NIPPV (BiPAP) reduces need for intubation and improves outcomes
• Loop diuretics are the cornerstone of treatment
• Don’t forget to identify and treat the trigger (ischemia, arrhythmia, infection)

When a patient walks into your ED with shortness of breath and legs that look like memory foam pillows, think CHF exacerbation. A good history, a sharp stethoscope, and a well-aimed ultrasound probe can save time and spare lungs. Load the Lasix, slap on the BiPAP (if needed), and find the trigger before their heart fails them again!

Want to learn more? Read our in-depth study guides and tune in to our podcast on other topics!

Cheers,

Tamir Zitelny, MD

-References-

1. Collins SP, Storrow AB, Levy PD, et al. Early management of patients with acute heart failure: state of the art and future directions. Circulation. 2016;134(9):e275-e285. doi:10.1161/CIR.0000000000000357
2. Pang PS, Collins SP, Sauser K, et al. The role of the emergency department in the management of acute heart failure. Curr Heart Fail Rep. 2020;17(4):140-150. doi:10.1007/s11897-020-00464-7
3. Mebazaa A, Yilmaz MB, Levy P, et al. Recommendations on pre-hospital & early hospital management of acute heart failure: a consensus paper from the Heart Failure Association of the ESC. Eur J Heart Fail. 2015;17(6):544-558. doi:10.1002/ejhf.289
4. Peacock WF, Fonarow GC, Emerman CL, et al. Impact of early initiation of intravenous therapy for acute decompensated heart failure on outcomes in ADHERE. Cardiol Clin. 2005;23(4):539-550. doi:10.1016/j.ccl.2005.07.009
5. Ezekowitz JA, Verma S, Armstrong PW. Safety and efficacy of diuretics in acute decompensated heart failure: insights from the DOSE-AHF trial. Eur Heart J. 2011;32(6):704-713. doi:10.1093/eurheartj/ehq471