Congestive heart failure acute pharmacotherapy: Difference between revisions
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==Overview== | ==Overview== | ||
The goals of acute treatment include: | The goals of acute treatment include: | ||
* Reduce [[preload]] | * Reduce [[preload]] | ||
| Line 10: | Line 9: | ||
* Improve [[cardiac contractility]] | * Improve [[cardiac contractility]] | ||
==Mainstays of Therapy== | |||
*Oxygen to improve oxygenation if [[hypoxemia]] is present. [[Positive airway pressure|Continuous positive airway pressure]] may be applied using a face mask; this has been shown to improve symptoms more quickly than oxygen therapy alone,<ref>{{cite journal |author=Gray A, Goodacre S, Newby DE, Masson M, Sampson F, Nicholl J |title=Noninvasive ventilation in acute cardiogenic pulmonary edema |journal=N. Engl. J. Med. |volume=359 |issue=2 |pages=142–51 |year=2008 |month=July |pmid=18614781|doi=10.1056/NEJMoa0707992}}</ref> and has been shown to reduce the risk of death.<ref>{{cite journal |author=Peter JV, Moran JL, Phillips-Hughes J, Graham P, Bersten AD |title=Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis |journal=Lancet |volume=367 |issue=9517 |pages=1155–63 |year=2006 |month=April |pmid=16616558|doi=10.1016/S0140-6736(06)68506-1}}</ref><ref>{{cite journal |author=Weng CL |title=Meta-analysis: Noninvasive ventilation in acute cardiogenic pulmonary edema |journal=Ann. Intern. Med. |volume=152 |issue=9 |pages=590–600 |year=2010 |month=May |pmid=20439577 |doi=10.1059/0003-4819-152-9-201005040-00009 |url= |author-separator=, |author2=Zhao YT |author3=Liu QH |display-authors=3 |last4=Fu |first4=CJ |last5=Sun |first5=F |last6=Ma |first6=YL |last7=Chen |first7=YW |last8=He |first8=QY}}</ref> Severe [[respiratory failure]] requires treatment with [[endotracheal intubation]] and [[mechanical ventilation]]. | *Oxygen to improve oxygenation if [[hypoxemia]] is present. [[Positive airway pressure|Continuous positive airway pressure]] may be applied using a face mask; this has been shown to improve symptoms more quickly than oxygen therapy alone,<ref>{{cite journal |author=Gray A, Goodacre S, Newby DE, Masson M, Sampson F, Nicholl J |title=Noninvasive ventilation in acute cardiogenic pulmonary edema |journal=N. Engl. J. Med. |volume=359 |issue=2 |pages=142–51 |year=2008 |month=July |pmid=18614781|doi=10.1056/NEJMoa0707992}}</ref> and has been shown to reduce the risk of death.<ref>{{cite journal |author=Peter JV, Moran JL, Phillips-Hughes J, Graham P, Bersten AD |title=Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis |journal=Lancet |volume=367 |issue=9517 |pages=1155–63 |year=2006 |month=April |pmid=16616558|doi=10.1016/S0140-6736(06)68506-1}}</ref><ref>{{cite journal |author=Weng CL |title=Meta-analysis: Noninvasive ventilation in acute cardiogenic pulmonary edema |journal=Ann. Intern. Med. |volume=152 |issue=9 |pages=590–600 |year=2010 |month=May |pmid=20439577 |doi=10.1059/0003-4819-152-9-201005040-00009 |url= |author-separator=, |author2=Zhao YT |author3=Liu QH |display-authors=3 |last4=Fu |first4=CJ |last5=Sun |first5=F |last6=Ma |first6=YL |last7=Chen |first7=YW |last8=He |first8=QY}}</ref> Severe [[respiratory failure]] requires treatment with [[endotracheal intubation]] and [[mechanical ventilation]]. | ||
*[[Diuretics]] reduce [[preload]] and reduce intravascular volume. Intravenous diuretics are often required in the acute setting. If high doses of furosemide are inadequate, boluses or continuous infusions of [[bumetanide]] may be preferred. These [[loop diuretics]] may be combined with [[thiazide diuretics]] such as oral [[metolazone]] or intravenous [[chlorthiazide]] for a synergistic effect. Intravenous preparations are preferred because of more predictable absorption. When a patient is extremely fluid overloaded, they can develop intestinal edema as well, which can affect enteral absorption of medications. | *[[Diuretics]] reduce [[preload]] and reduce intravascular volume. Intravenous diuretics are often required in the acute setting. If high doses of furosemide are inadequate, boluses or continuous infusions of [[bumetanide]] may be preferred. These [[loop diuretics]] may be combined with [[thiazide diuretics]] such as oral [[metolazone]] or intravenous [[chlorthiazide]] for a synergistic effect. Intravenous preparations are preferred because of more predictable absorption. When a patient is extremely fluid overloaded, they can develop intestinal edema as well, which can affect enteral absorption of medications. | ||
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*[[Morphine]] reduces [[preload]], reduces [[catecholamines]], and reduces the stimulation by stretch receptors in the lung thereby improving symptoms of [[dyspnea]]. | *[[Morphine]] reduces [[preload]], reduces [[catecholamines]], and reduces the stimulation by stretch receptors in the lung thereby improving symptoms of [[dyspnea]]. | ||
==More Aggressive Pharmacotherapy== | |||
*[[Nitroprusside]] reduces [[afterload]] and reduces [[preload]] | *[[Nitroprusside]] reduces [[afterload]] and reduces [[preload]] | ||
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*[[Dopamine]] increases blood pressure and increases renal perfusion at low doses | *[[Dopamine]] increases blood pressure and increases renal perfusion at low doses | ||
*[[Nesiritide]] reduces [[afterload]] and reduces [[preload]] and can be used if other therapies have not been effective. | *[[Nesiritide]] reduces [[afterload]] and reduces [[preload]] and can be used if other therapies have not been effective. | ||
==References== | ==References== | ||
Revision as of 02:42, 4 April 2012
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
The goals of acute treatment include:
- Reduce preload
- Reduce afterload
- Reduce intravascular volume
- Improve cardiac contractility
Mainstays of Therapy
- Oxygen to improve oxygenation if hypoxemia is present. Continuous positive airway pressure may be applied using a face mask; this has been shown to improve symptoms more quickly than oxygen therapy alone,[1] and has been shown to reduce the risk of death.[2][3] Severe respiratory failure requires treatment with endotracheal intubation and mechanical ventilation.
- Diuretics reduce preload and reduce intravascular volume. Intravenous diuretics are often required in the acute setting. If high doses of furosemide are inadequate, boluses or continuous infusions of bumetanide may be preferred. These loop diuretics may be combined with thiazide diuretics such as oral metolazone or intravenous chlorthiazide for a synergistic effect. Intravenous preparations are preferred because of more predictable absorption. When a patient is extremely fluid overloaded, they can develop intestinal edema as well, which can affect enteral absorption of medications.
- Nitroglycerine reduces afterload and reduces preload. Nitroglycerine is helpful in improving symptoms of dyspnea.
- Morphine reduces preload, reduces catecholamines, and reduces the stimulation by stretch receptors in the lung thereby improving symptoms of dyspnea.
More Aggressive Pharmacotherapy
- Nitroprusside reduces afterload and reduces preload
If the patient's circulatory volume is adequate but there is persistent evidence of inadequate end-organ perfusion, inotropes may be administered.
- Milrinone increases contractility and reduces afterload
- Dobutamine increases contractility in reduces afterload
- Dopamine increases blood pressure and increases renal perfusion at low doses
- Nesiritide reduces afterload and reduces preload and can be used if other therapies have not been effective.
References
- ↑ Gray A, Goodacre S, Newby DE, Masson M, Sampson F, Nicholl J (2008). "Noninvasive ventilation in acute cardiogenic pulmonary edema". N. Engl. J. Med. 359 (2): 142–51. doi:10.1056/NEJMoa0707992. PMID 18614781. Unknown parameter
|month=ignored (help) - ↑ Peter JV, Moran JL, Phillips-Hughes J, Graham P, Bersten AD (2006). "Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis". Lancet. 367 (9517): 1155–63. doi:10.1016/S0140-6736(06)68506-1. PMID 16616558. Unknown parameter
|month=ignored (help) - ↑ Weng CL; Zhao YT; Liu QH; et al. (2010). "Meta-analysis: Noninvasive ventilation in acute cardiogenic pulmonary edema". Ann. Intern. Med. 152 (9): 590–600. doi:10.1059/0003-4819-152-9-201005040-00009. PMID 20439577. Unknown parameter
|month=ignored (help); Unknown parameter|author-separator=ignored (help)