Acute management

Recommended treatments for all patients

• IV loop diuretics
  • e.g. furosemide or bumetanide

Possible additional treatments

• oxygen
  • this should be given in line with British Thoracic Society guidelines, i.e. keep oxygen saturations at 94-98%
• vasodilators
  • e.g. IV GTN, isosorbide dinitrate or sodium nitroprusside infusion
  • reduce preload and afterload
  • nitrates should not be routinely given to all patients, may be considered if systolic BP > 100 mmHg
  • they may, however, have a role if concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease
  • the major side-effect/contraindication is hypotension

Chest x-ray showing pulmonary oedema - e Image used on license from Radiopaedia

Patients with respiratory failure

• CPAP

Patients with hypotension (e.g. < 85 mmHg)/cardiogenic shock

• this can be a difficult scenario to manage
  • some of the treatments typically used for acute heart failure (e.g. loop diuretics and nitrates) may exacerbate the hypotension
• inotropic agents
  • e.g. dobutamine
  • should be considered for patients with severe left ventricular dysfunction who have potentially reversible cardiogenic shock
• vasopressor agents
  • e.g. norepinephrine
  • normally only used if insufficient response to inotropes and evidence of end-organ hypoperfusion
• mechanical circulatory assistance
  • e.g. intra-aortic balloon counterpulsation or ventricular assist devices

Other treatments

• opiates
  • NICE state 'do not routinely offer opiates to people with acute heart failure'
  • they were previously used routinely and help to reduce dyspnoea/distress in patients
  • however some studies have suggested increased morbidity in patients given opiates

General points

• regular medication for heart failure such as beta-blockers ACE-inhibitors should be continued
  • beta-blockers should only be stopped if the patient has heart rate less than 50 beats per minute, second or third degree atrioventricular block, or shock