In this week’s episode, Eric is joined by Dr. Tark, now 3rd year resident, to break down the recognition and management of acute heart failure exacerbation.

Key Discussion Points:

• Patient Presentation: Common symptoms include peripheral edema, pulmonary congestion with dyspnea, and paroxysmal nocturnal dyspnea. Physical exam findings such as S3/S4 gallops, jugular venous distension, and hepatic jugular reflux play a critical role in making a clinical diagnosis.
• Workup: While BNP is frequently ordered, heart failure remains a clinical diagnosis. Supportive labs include CMP, renal function, troponins, ECG, and occasionally lactate in suspected shock. Chest X-ray can confirm pulmonary congestion, and echocardiography helps define the type of HF (HFrEF vs. HFpEF).
• Management:
  • Diuretics remain the cornerstone—IV loop diuretics with escalation as needed, targeting 2–3 L of diuresis in the first 24 hours.
  • Acetazolamide has emerged as a promising adjunct. The ADVOR Trial (Mullens et al., NEJM 2022) showed that adding acetazolamide to loop diuretics in acute decompensated HF increased decongestion rates and reduced hospital stay.
  • Non-invasive ventilation (CPAP/BiPAP) provides symptomatic relief in flash pulmonary edema by improving oxygenation and reducing preload/afterload.
• Guideline-Directed Medical Therapy (GDMT):
  • Beta-blockers should be continued in stable patients but held in cardiogenic shock.
  • ACE inhibitors/ARBs/ARNIs and SGLT2 inhibitors are central pillars of therapy in chronic HFrEF, with trials like DAPA-HF and EMPEROR-Reduced demonstrating mortality and hospitalization benefits.
  • SGLT2 inhibitors also benefit patients with HFpEF, as shown in EMPEROR-Preserved

Pearls and Pitfalls:

• BNP should be interpreted in context
• Always rule out mimickers such as pulmonary embolism, ischemic events, arrhythmias, thyroid disease, and infections.
• Early and aggressive diuresis in the first 24–48 hours can shape the patient’s entire trajectory of recovery.

Takeaway: Acute heart failure requires a careful balance of clinical recognition, judicious use of diagnostics, and evidence-based diuretic strategies. Early intervention, guided by both bedside exam and trial evidence, makes the difference between stabilization and deterioration.

References:

1. Felker GM, et al. "Diuretic Strategies in Patients with Acute Decompensated Heart Failure" NEJM. 2011;364:797–805. (DOSE Trial)
2. Mullens W, et al. "Acetazolamide in Acute Decompensated Heart Failure with Volume Overload." NEJM. 2022;387:1185–1195. (ADVOR Trial)
3. McMurray JJV, et al. "Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction." NEJM. 2019;381:1995–2008. (DAPA-HF)
4. Packer M, et al. "Cardiovascular and Renal Outcomes with Empagliflozin in Heart Failure." NEJM. 2020;383:1413–1424. (EMPEROR-Reduced)
5. Anker SD, et al. "Empagliflozin in Heart Failure with a Preserved Ejection Fraction." NEJM. 2021;385:1451–1461. (EMPEROR-Preserved)