Congestive heart failure acute pharmacotherapy
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Acute Pharmacotherapy
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.
Ultrafiltration
- Ultrafiltration has been associated with a reduced incidence of hospitalization compared with diuretics in the UNLOAD trial. There was no difference in mortality.
- Ultrafiltration removes plasma water from whole blood. Possible benefits of ultrafiltration include:
- Provides fluid regulation
- Relieve pulmonary edema
- Reduce ascites and/or peripheral edema
- Hemodynamic stabilization
- Improve oxygenation
- Facilitates blood product replacement without excess volume
- Enable parenteral nutritional support without excess volume
- Improves solute regulation
- Correct acid-base balance
- Correct serum sodium content
- Eliminate myocardial depressant factors or known toxins
- Correct uremia
- Correct hyperkalemia
- Correct other electrolyte disturbances
- Helps to establish homeostasis
- Reset water omostat
- Restore diuretic responsiveness
- Reduce neurohormonal activation
Chronic Pharmacotherapy
Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
- Cardiac resynchronization therapy should only be undertaken if the blood pressure is low and if the heart failure medicines have been optimized
- CRT is indicated for symptomatic patients with NYHA III-IV heart failure and wide QRS complex (>120ms) who are him normal sinus rhythm.
- 70% of patients receiving synchronous ventricular contraction report significant symptomatic improvements.
ACC / AHA Guidelines - Recommendations for Cardiac Resynchronization Therapy in Patients with Severe Systolic Heart Failure (DO NOT EDIT)[4]
| “ |
Class I1. For patients who have LVEF less than or equal to 35%, a QRS duration greater than or equal to 0.12 seconds, and sinus rhythm, CRT with or without an ICD is indicated for the treatment of NYHA functional Class III or ambulatory Class IV heart failure symptoms with optimal recommended medical therapy. (Level of Evidence: A) Class IIa1. For patients who have LVEF less than or equal to 35%, a QRS duration greater than or equal to 0.12 seconds, and AF, CRT with or without an ICD is reasonable for the treatment of NYHA functional Class III or ambulatory Class IV heart failure symptoms on optimal recommended medical therapy. (Level of Evidence: B) 2. For patients with LVEF less than or equal to 35% with NYHA functional Class III or ambulatory Class IV symptoms who are receiving optimal recommended medical therapy and who have frequent dependence on ventricular pacing, CRT is reasonable. (Level of Evidence: C) Class IIb1. For patients with LVEF less than or equal to 35% with NYHA functional Class I or II symptoms who are receiving optimal recommended medical therapy and who are undergoing implantation of a permanent pacemaker and/or ICD with anticipated frequent ventricular pacing, CRT may be considered. (Level of Evidence: C) |
” |
Implantation of Intracardiac Defibrillator
- 50% of heart failure patients die of sudden cardiac death.
- ICDs are indicated for patients with previous myocardial infarction and LVEF <30%, sustained ventricular tachycardia, inducible ventricular tachycardia.
- Morbidity/mortality benefit of ICD placement vs. anti-arrhythmic drug therapy is controversial.
Cardiac Surgery
- Resection of non-viable myocardium or aneurymectoymay be an option to improve left ventricular geometry
- Revascularization without resection of non-viable myocardium may be helpful if there is hibernating myocardium
Left Ventricular Assist Devices (LVADs)
- LVADs are temporary devices to bridge end stage patients to cardiac transplantation.
- The use of LVADs as a destination device rather than as a bridge is investigational at present
Cardiac Transplantation
- Cardiac transplantation is reserved for patients with end-stage congestive heart failure despite all interventions.
- AHA/ACC Guidelines: Indications for heart transplantation:
- Any hemodynamic compromise due to heart failure.
- Requiring IV inotropic support to maintain adequate organ perfusion.
- Peak Vo2 <10 ml/kg/min.
- NYHA Class IV symptoms not amenable to any other intervention.
- Recurrence of symptomatic ventricular arrhythmias refractory to all therapeutic intervention.
- AHA/ACC Guidelines: Indications for heart transplantation:
- 80% 1 year survival, and 60% 5 year survival.
- Lifelong immunosuppressive therapy to prevent (or postpone) rejection, increased risk for opportunistic infections and malignancies.
Invasive Monitoring
- Based upon the results of the ESCAPE trial, there is no benefit in clinical outcomes with the use of a pulmonary artery line in patients with decompensated CHF.
Obstructive Sleep Apnea in the Patient with CHF
- Central sleep apnea in the patient with CHF is due to the compensatory respiratory alkalosis that is present in the patient with CHF and tachypnea
Exercise and Daily Activities
- Patient should have uninterrupted exercise at least four days a week including a walking program.
- Patients with heart failure should avoid weightlifting which increases afterload.
- The patient should not routinely lift more than 20 pounds, again which may increase afterload.
- Patients can continue their sexual activity. Some patients take 2.5 or 5.0 mg of sublingual nitroglycerine before sexual activity.
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) - ↑ Epstein AE, DiMarco JP, Ellenbogen KA, Estes NA, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO, Smith SC, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Faxon DP, Halperin JL, Hiratzka LF, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura RA, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW (2008). "ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons". Circulation. 117 (21): e350–408. doi:10.1161/CIRCUALTIONAHA.108.189742. PMID 18483207. Retrieved 2011-01-15. Unknown parameter
|month=ignored (help)