Congestive heart failure acute pharmacotherapy

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Acute Pharmacotherapy
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Chronic Pharmacotherapy in HFrEF Diuretics ACE Inhibitors Angiotensin receptor blockers Aldosterone Antagonists Beta Blockers Ca Channel Blockers Nitrates Hydralazine Positive Inotropics Anticoagulants Angiotensin Receptor-Neprilysin Inhibitor Antiarrhythmic Drugs Nutritional Supplements Hormonal Therapies Drugs to Avoid Drug Interactions Treatment of underlying causes Associated conditions
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ACC/AHA Guideline Recommendations Initial and Serial Evaluation of the HF Patient Hospitalized Patient Patients With a Prior MI Sudden Cardiac Death Prevention Surgical/Percutaneous/Transcather Interventional Treatments of HF Patients at high risk for developing heart failure (Stage A) Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B) Patients with current or prior symptoms of heart failure (Stage C) Patients with refractory end-stage heart failure (Stage D) Coordinating Care for Patients With Chronic HF Quality Metrics/Performance Measures
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Congestive heart failure end-of-life considerations
Specific Groups: Special Populations Patients who have concomitant disorders Obstructive Sleep Apnea in the Patient with CHF NSTEMI with Heart Failure and Cardiogenic Shock
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: acute decompensated heart failure, ADHF, flash pulmonary edema

Overview

Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as acute decompensated heart failure, flash pulmonary edema, ADHF). CT HF presents with acute shortness of breath due to the development of pulmonary edema (the rapid accumulation of fluid in the lung). ADHF associated with a poor prognosis if not treated aggressively. Hospitalization is required for the management of the patient. The mainstays of the acute medical treatment in congestive heart failure include oxygen to improve hypoxia, diuresis to reduce both preload and intravascular volume and vasodilators to reduce afterload.

Medical Therapy

Treatment Goals

• Reduce preload
• Reduce afterload
• Reduce intravascular volume
• Improve cardiac contractility

Management Plan

Oxygen

• Oxygen improves the patient's status 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, and has been shown to reduce the risk of death. Severe respiratory failure requires treatment with endotracheal intubation and mechanical ventilation.

Diuretics

• 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

• Nitroglycerine reduces afterload and reduces preload. Nitroglycerine is helpful in improving symptoms of dyspnea.

Morphine

• 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
• Ionotropes may be administered if the patient's circulatory volume is adequate but there is persistent evidence of inadequate end-organ perfusion.
• 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

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