Acute Decompensated Heart Failure: Diuresis, Vasodilators & Ultrasound Congestion Map

The fastest way to make patients with acute heart failure (ADHF) feel better and live longer is early decongestion with the right loop diuretic dose, smart afterload reduction in hypertensive pulmonary edema, and meticulous reassessment (urine output, weights, electrolytes, ultrasound).

Recognition & Initial Triage

• Symptoms: orthopnea, PND, dyspnea, edema, rapid weight gain, fatigue.
• Exam: JVP elevation, S3, crackles/B-lines, edema, cool extremities (hypoperfusion).
• Key tests: ECG, troponin, natriuretic peptide (BNP/NT-proBNP), CXR, basic labs (BMP/Mg, LFTs), ABG/VBG if hypoxic or hypercapnic.
• Differentiate from COPD/asthma, pneumonia, PE, tamponade, and ARDS with history + bedside ultrasound.

Immediate Stabilization

• Oxygen: titrate to SpO₂ 92–96% (or baseline for chronic hypoxemia).
• NIV (BiPAP): for acute pulmonary edema with tachypnea/distress or hypercapnia; reduces preload/afterload and intubation risk.
• Nitrates early for hypertensive flash pulmonary edema: IV nitroglycerin (e.g., 20–40 mcg/min and uptitrate rapidly as BP tolerates). Avoid if hypotensive, RV infarct, or severe aortic stenosis.

Loop Diuretic Strategy (core therapy)

• If loop-naïve: start furosemide 20–40 mg IV (or bumetanide 0.5–1 mg IV) and reassess in 2 hours.
• If on home loop: give an IV dose ≈ 1–2.5× the patient’s total daily oral furosemide-equivalent as the first 24 h target, split q8–12h or by infusion.
  Equivalents (approx): furosemide 40 mg PO ≈ furosemide 20 mg IV ≈ torsemide 20 mg PO ≈ bumetanide 1 mg PO/IV.
• Assess response at 2 hours: urine output goal ≳ 150 mL/h early, or spot urine sodium after the first dose > 50–70 mmol/L suggests adequate natriuresis.
• If poor response: double the loop dose; consider continuous infusion; add a thiazide-type agent (e.g., chlorothiazide IV or metolazone PO) for sequential nephron blockade.
• Electrolytes: keep K⁺ 4.0–5.0 mEq/L and Mg²⁺ ≥2.0 mg/dL; monitor BMP/Mg every 6–12 h during aggressive diuresis.
• Targets (first 24 h): net negative ~1–2 L (individualize by blood pressure, kidneys, and congestion severity).

Afterload Reduction & BP Management

• Hypertensive ADHF: IV nitroglycerin is first-line; nitroprusside for severe afterload excess with invasive BP monitoring when available.
• Nitrates + NIV are synergistic in flash pulmonary edema.
• Avoid routine IV beta-blockers in acute decompensation; continue home beta-blocker unless shock, severe bradycardia, or need for inotropy.

Ultrasound Congestion Map (guide therapy)

• Lung: quantify B-lines (8-zone count). Falling B-lines track decongestion.
• IVC: diameter and collapsibility; combine with venous Doppler (VExUS—hepatic, portal, intrarenal) to judge venous congestion and kidney risk.
• Heart: limited echo for LV/RV function, pericardial effusion, gross valvular disease.
• Bladder: exclude retention if poor urine output.

Renal Considerations & Diuretic Resistance

• Worsening creatinine during effective decongestion can be transient; prioritize relief of congestion if perfusion is adequate and K⁺ is safe.
• Adjuncts: consider acetazolamide for metabolic alkalosis/diuretic synergy; add thiazide-type as above.
• Ultrafiltration for refractory volume overload after optimized pharmacologic therapy; coordinate with nephrology.

Cardiogenic Shock Pathway (brief)

• Identify hypoperfusion: altered mentation, cold/clammy skin, rising lactate, oliguria.
• Norepinephrine for MAP; dobutamine (or milrinone) for low cardiac output once BP supported.
• Early echo/hemodynamics; evaluate for mechanical complications, acute MI, or severe valve disease; consider mechanical circulatory support in appropriate centers.

After Stabilization: Disease-Modifying Therapy

• Optimize/introduce GDMT as tolerated: ACEi/ARB/ARNI, evidence beta-blocker, MRA, and SGLT2 inhibitor.
• Check iron studies; give IV iron for iron deficiency to improve symptoms/readmissions in HFrEF.
• Address triggers: AF with RVR, ischemia, dietary indiscretion, NSAIDs, infection, anemia, thyroid disease, renal injury.

Discharge Readiness & Follow-Up

• Near-euvolemia: minimal edema, no orthopnea, few B-lines, JVP near normal.
• Stable creatinine/electrolytes and off IV diuretics for 24 h.
• Oral diuretic plan with weight-based self-titration, sodium restriction guidance, and follow-up within 7 days.
• Education: daily weights, when to call, med adherence, vaccination.

Patient FAQs

“Why am I peeing so much?” Removing extra salt and water unloads your heart and lungs so you can breathe easier.

“Will diuretics hurt my kidneys?” We watch your labs closely—mild creatinine bumps can be acceptable while we relieve congestion; dangerous trends trigger a change of plan.

References & Notes

Pragmatic ADHF pathway: NIV + nitrates for hypertensive edema, aggressive but monitored loop diuresis with urine sodium checks, ultrasound-guided decongestion, and shock management when present. Start/optimize GDMT before discharge. Local protocols vary—follow institutional guidance. Educational only.