Acute exacerbations of chronic heart failure (ADCHF) are among the most common causes of emergency department visits and hospital admissions worldwide. They are often triggered by nonadherence to therapy, dietary indiscretions, comorbid conditions, or disease progression. These episodes require prompt recognition, risk stratification, and evidence-based intervention to reduce morbidity, mortality, and rehospitalization.

Neftaly’s Acute Care Protocol provides a clear, practical framework for healthcare providers to manage acute decompensated heart failure effectively in both emergency and clinical settings.

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1. Objectives of Acute Care Management

• Rapidly identify decompensation in heart failure patients
• Relieve symptoms and stabilize hemodynamic status
• Identify and treat precipitating factors
• Optimize ongoing heart failure therapy
• Prevent readmission through structured discharge planning and education

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2. Clinical Presentation

Common Symptoms:

• Dyspnea (especially orthopnea, PND)
• Rapid weight gain
• Peripheral edema (legs, sacrum)
• Fatigue and weakness
• Abdominal bloating or discomfort
• Cough, often worse when lying flat

Physical Signs:

• Elevated jugular venous pressure (JVP)
• Bibasilar crackles or rales
• S3 gallop rhythm
• Cool extremities
• Hypotension or tachycardia

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3. Initial Assessment and Triage

Vital Signs and Monitoring:

• Blood pressure, heart rate, respiratory rate, O₂ saturation
• Continuous ECG monitoring
• Daily weights and strict input/output monitoring

Focused History:

• Recent weight gain, missed medications, dietary indiscretion
• Comorbidities: atrial fibrillation, renal disease, diabetes
• Current medications and any recent changes

Common Triggers:

• Infections (e.g., pneumonia, UTI)
• Myocardial ischemia
• Uncontrolled hypertension
• Nonadherence to meds or diet
• Arrhythmias (especially atrial fibrillation)

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4. Diagnostic Workup

Test	Purpose
ECG	Detect arrhythmias or ischemia
Chest X-ray	Check for pulmonary edema, pleural effusions
BNP or NT-proBNP	Confirm/exclude heart failure as cause of dyspnea
Echocardiogram (if not recent)	Assess ejection fraction, wall motion, valve function
Blood tests: CBC, electrolytes, renal function, troponins, LFTs, glucose	Rule out infection, renal failure, electrolyte imbalance, ACS

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5. Neftaly Classification of Acute Heart Failure

Type	Features	Management Focus
Warm and Wet	Adequate perfusion, fluid overload	Diuretics, vasodilators
Cold and Wet	Poor perfusion, fluid overload	Inotropes, vasodilators, diuretics
Warm and Dry	Stable, compensated	Maintain therapy
Cold and Dry	Hypoperfusion, volume depleted	Fluids, inotropes

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6. Acute Management Protocol

A. Oxygen Therapy

• Administer if SpO₂ < 90%
• Consider CPAP or BiPAP if severe dyspnea or respiratory distress

B. Diuretics (First-Line)

• IV furosemide 20–40 mg (or higher for chronic users)
• Monitor urine output and renal function
• Titrate based on symptom relief and weight loss

C. Vasodilators (If BP permits)

• Nitroglycerin (sublingual or IV infusion)
• Reduces preload and improves dyspnea

D. Inotropes (if hypotension with signs of hypoperfusion)

• Dobutamine or Milrinone under ICU monitoring
• Used in “cold and wet” patients or cardiogenic shock

E. Treat Underlying Cause

• Antibiotics for infection
• Anticoagulation for atrial fibrillation if needed
• PCI or antiplatelet therapy if ACS is suspected

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7. Monitoring and Supportive Care

• Daily weights
• Renal function and electrolytes every 24–48 hours
• Monitor for hypokalemia or hyponatremia
• Adjust medications (ACEi/ARB/ARNI, beta-blockers) based on stability

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8. Criteria for Hospital Admission

Admit If:

• Severe dyspnea or hypoxia
• Hypotension or shock
• Acute kidney injury
• New arrhythmias
• Syncope or altered mental status
• Inadequate response to initial therapy
• Poor support at home

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9. Discharge Planning and Education

Discharge should only occur when:

• Volume status is near euvolemia
• Symptoms are controlled
• Patient is ambulating and tolerating oral meds
• Clear follow-up plan is in place

Key Components of Discharge:

• Reinstate or initiate guideline-directed medical therapy (GDMT)
• Provide weight diary and medication list
• Educate on salt/fluid restriction, warning signs
• Arrange close outpatient follow-up within 7 days

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10. Neftaly Patient Education Essentials

• Daily weight monitoring (report >2 kg increase in 2 days)
• Low-sodium diet (<2g/day)
• Fluid restriction (1.5–2L/day if hyponatremic)
• Medication adherence (beta-blockers, ACE inhibitors, diuretics)
• Recognize signs of worsening: increased swelling, shortness of breath, fatigue

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11. Neftaly Clinical Checklist for Acute Heart Failure

✅ ABCs and oxygenation
✅ History, vitals, physical exam
✅ ECG, labs, CXR, BNP
✅ IV diuretics ± vasodilators or inotropes
✅ Identify and treat triggers
✅ Monitor electrolytes, kidney function
✅ Plan for safe discharge and follow-up
✅ Educate patient and family

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12. Conclusion

Acute exacerbations of chronic heart failure demand swift, structured intervention to prevent deterioration. The Neftaly Acute Care Protocol ensures providers are equipped to recognize decompensation early, apply evidence-based treatments, and coordinate care for long-term stability. By closing the loop with education and follow-up, Neftaly promotes better outcomes and fewer readmissions.