CHF Workup and Treatment Guide

Congestive Heart Failure

I. Initial Evaluation

History

  • Symptoms: Dyspnea (orthopnea, PND), fatigue, edema, weight gain
  • Triggers: Ischemia, arrhythmia, infection, medication (diuretic) non-compliance, renal failure, anemia
  • History: CAD, HTN, diabetes, valvular disease, prior CHF

Physical Exam

  • Vitals: Hypertension or Hypotension (worse), tachypnea, hypoxia
  • Lungs: Crackles, rales, pleural effusion → diminished bases
  • Cardiac: S3 gallop, displaced PMI, murmurs
  • Peripheral: JVD, edema, hepatomegaly

II. Diagnostic Workup

Labs

  • BNP / NT-proBNP – supports CHF diagnosis
  • Troponin – rule out ACS
  • CMP – renal, electrolytes
  • CBC – anemia, infection
  • TSH – rule out thyroid dysfunction
  • ABG or lactate – if hypoxia or concern for shock

Imaging

  • Chest X-ray: Cardiomegaly, pulmonary vascular congestion, pleural effusion
  • EKG: Ischemia, Afib, LVH
  • POCUS: B-lines, IVC > 2.5cm, r/o pericardial effusion, LV function
  • Formal Echo: Ejection fraction and valvular function
    • This does not need to be done in the ED

III. Classification

By Ejection Fraction

  • HFrEF (reduced ejection fraction): EF < 40%
  • HFpEF (preserved ejection fraction): EF > 50%
  • HFmrEF (mid-range ejection fraction): EF 41–49%

By Clinical Profile

Profile Perfusion Volume
Warm & Wet Normal Hypervolemic
Cold & Wet Hypoperfused Hypervolemic
Cold & Dry Hypoperfused Hypovolemic or Euvolemic
Warm & Dry Normal Euvolemic

IV. Treatment

Acute Decompensated CHF

  • IV Diuretics: Furosemide or Bumetanide; monitor renal and electrolyte status
    • Give the patient their daily PO furosemide or bumetanide dose as IV
    • If their dose is unknown, start with furosemide 40-80mg IV or bumetanide 1mg IV
  • Vasodilators: Nitroglycerin in hypertensive or pulmonary edema patients
    • Depending on the severity of their respiratory status you can give 0.4mg SL NTG x 3 followed by a 1 inch NTG paste on their chest, or if they are in severe distress you can start 200 mcg/min of IV nitroglycerin and this can be increased to 400 mcg/min if their blood pressure can tolerate it.
  • Oxygen/BiPAP: For hypoxia or respiratory distress
  • Inotropes: Dobutamine or milrinone if cold/shock state
    • These are best used when the patient is hypervolemic, hypotensive and thus in a hypoperfusing state. Once you have improved their cardiac output (and thus their blood pressure), they can begin to be carefully diuresed

Chronic Outpatient Management (HFrEF)

  • ACEi / ARB: Lisinopril, Benazepril
  • Beta-blockers: Carvedilol, Metoprolol succinate
  • Mineralocorticoid antagonists: Spironolactone
  • SGLT2 inhibitors: Empagliflozin or Dapagliflozin
  • Loop diuretics: Furosemide or Bumetanide

V. Disposition Planning

Scenario Disposition Notes
Mild, improving with treatment Discharge or observation Stable vitals, reliable follow-up
Moderate symptoms needing IV diuretics Admit to telemetry floor Most ADCHF patients
Shock, respiratory failure, unstable arrhythmia ICU Advanced care: inotropes, pressors, ventilation

VI. Red Flags / Escalation Triggers

  • Persistent hypotension or shock state
  • Elevated troponin suggesting ACS
  • Refractory hypoxia or respiratory failure
  • New arrhythmias (Afib with RVR, VT/VF)
  • Worsening renal function
  • Concern for tamponade or PE

✅ Discharge Checklist

  • Stable vitals
  • Symptomatic improvement after diuresis
  • No new oxygen requirement and no increased respiratory effort
  • Discharge meds reviewed and optimized, refills sent to pharmacy if needed
  • Follow-up with cardiology or PCP
  • Patient education on sodium/water restriction and daily weight

References

  1. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
    J Am Coll Cardiol. 2022;79(17):e263-e421.
    https://www.jacc.org/doi/10.1016/j.jacc.2021.12.012
  2. McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.
    Eur Heart J. 2021;42(36):3599-3726.
    https://academic.oup.com/eurheartj/article/42/36/3599/6358045
  3. American College of Emergency Physicians (ACEP). Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Acute Heart Failure Syndromes.
    Ann Emerg Med. 2007;49(4):627-669.
    https://doi.org/10.1016/j.annemergmed.2006.11.021

Additional Keywords: CHF, Congestive Heart Failure, Pulmonary Edema, Ejection Fraction, Fluid Overload