Acute heart failure - Revision history

Aidan: /* Management */

2021-10-14T17:31:51Z

Management

← Older revision		Revision as of 17:31, 14 October 2021
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	***Alternately, vasoconstrictor therapy with [[dopamine]]		***Alternately, vasoconstrictor therapy with [[dopamine]]
	***Mechanical cardiac support		***Mechanical cardiac support
	**Start ~~[[ACEi]]~~ 24-48h into admission, if BP and renal function allow, followed by [[β-blocker]] (if tolerated)		**Start ARNI 24-48h into admission, if BP and renal function allow, followed by [[β-blocker]] (if tolerated)
			**They should be switched to or started on an ARNI, in preference to ACEi/ARB
	*Left-sided heart failure with preserved ejection fraction		*Left-sided heart failure with preserved ejection fraction
	**Control blood pressure (most common cause is hypertension)		**Control blood pressure (most common cause is hypertension)

Aidan: /* Discharge */

2021-02-22T02:19:42Z

Discharge

← Older revision		Revision as of 02:19, 22 February 2021
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	*[[Hydromorphone]] or [[morphine]] for pain and dyspnea		*[[Hydromorphone]] or [[morphine]] for pain and dyspnea

	=== Discharge ===		===Discharge===

	* Reinforce education		*Reinforce education
	** Low-salt diet		**Low-salt diet
	**Daily weights, and logging		**Daily weights, and logging
	**Alert CHF clinic if dizzy or gained/lost 3lbs		**Alert CHF clinic if dizzy or gained/lost 3lbs
	*Document discharge weight and discharge BNP		*Document discharge weight and discharge BNP
	*Ensure β-blocker and ACEi/ARB are started, if appropriate		*Ensure β-blocker and ACEi/ARB are started, if appropriate
			*See also [[Chronic heart failure#Management\|Chronic heart failure]]

	[[Category:Cardiology]]		[[Category:Cardiology]]

Aidan: /* Supportive Treatment */

2021-02-22T02:11:11Z

Supportive Treatment

← Older revision		Revision as of 02:11, 22 February 2021
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	#Further increase in filling pressure and decreased cardiac output (decompensation)		#Further increase in filling pressure and decreased cardiac output (decompensation)

	== Clinical Manifestations ==		==Clinical Manifestations==

	* Hypoperfusion, with fatigue, weakness, confusion, and pale, cool, and moist extremities		*Hypoperfusion, with fatigue, weakness, confusion, and pale, cool, and moist extremities
	* Circulatory congestion		*Circulatory congestion
	** RV failure: peripheral edema, JV distension, epigastric tenderness from hepatomegaly, pleural or pericardial effusions		**RV failure: peripheral edema, JV distension, epigastric tenderness from hepatomegaly, pleural or pericardial effusions
	** LV failure: pulmonary edema with dyspnea, tachypnea, orthopnea, and crackles on auscultation		**LV failure: pulmonary edema with dyspnea, tachypnea, orthopnea, and crackles on auscultation
	* Common symptoms include progressive exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea		*Common symptoms include progressive exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea

	{\| class="wikitable"		{\| class="wikitable"
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	\|}		\|}

	== Investigations ==		==Investigations==

	* ECG to assess for [[myocardial infarction]], [[arrhythmia]], and [[conduction abnormalities]]		*ECG to assess for [[myocardial infarction]], [[arrhythmia]], and [[conduction abnormalities]]
	* Chest x-ray for evidence of pulmonary congestion, pleural effusion, or cardiomegaly		*Chest x-ray for evidence of pulmonary congestion, pleural effusion, or cardiomegaly
	* Echocardiography		*Echocardiography
	* Laboratory tests		*Laboratory tests
	** Routine, including CBC, creatinine, electrolytes, liver enzymes, ± ABG		**Routine, including CBC, creatinine, electrolytes, liver enzymes, ± ABG
	** Cardiac-specific, including troponin and BNP/NT-proBNP		**Cardiac-specific, including troponin and BNP/NT-proBNP

	==Management==		==Management==
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	*Treat underlying condition and acute precipitant		*Treat underlying condition and acute precipitant
	*Continue home β-blocker and ACEi/ARB unless hypotensive or bradycardic		*Continue home β-blocker and ACEi/ARB unless hypotensive or bradycardic
	*Left-sided heart failure ~~is managed primarily~~ with ~~vasodilators, loop diuretics, and~~ ~~mechanical~~ ~~ventilation~~		*Left-sided heart failure with reduced ejection fraction
			**Managed primarily with vasodilators, loop diuretics, and mechanical ventilation
	**High BP		**High BP
	***Vasodilators with [[nitroglycerine]], [[nitroprusside]], or [[nesiritide]]		***Vasodilators with [[nitroglycerine]], [[nitroprusside]], or [[nesiritide]]
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	***Mechanical cardiac support		***Mechanical cardiac support
	**Start [[ACEi]] 24-48h into admission, if BP and renal function allow, followed by [[β-blocker]] (if tolerated)		**Start [[ACEi]] 24-48h into admission, if BP and renal function allow, followed by [[β-blocker]] (if tolerated)
			*Left-sided heart failure with preserved ejection fraction
			**Control blood pressure (most common cause is hypertension)
			**ACEi/ARB, especially [[candesartan]]
			**Consider aldosterone antagonist (e.g. [[spirolonactone]])
			**Monitor and maintain volume status
	*Isolated right-sided heart failure		*Isolated right-sided heart failure
	**Avoid vasodilators (including ACEi/ARBs) and diuretics		**Avoid vasodilators (including ACEi/ARBs) and diuretics
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	**Occasionally need [[dopamine]]		**Occasionally need [[dopamine]]

	=== Vasodilators ===		===Vasodilators===

	* [[Nitroglycerin]] 10 to 20 mcg/min IV, increased by 5 to 10 mcg/min every 3 to 5 minutes as tolerated by SBP		*[[Nitroglycerin]] 10 to 20 mcg/min IV, increased by 5 to 10 mcg/min every 3 to 5 minutes as tolerated by SBP
	** Maximum 200 mcg/min		**Maximum 200 mcg/min
	** ~~Alternately~~, can be given translingually 400 mcg every 5 to 10 minutes (usually the dose of 1 spray)		**Alternatively, can be given translingually 400 mcg every 5 to 10 minutes (usually the dose of 1 spray)
			**Alternatively, can be given as transdermal patch 0.4-0.8 mg/h
	** Used for short period of time because tolerance develops within 24 to 48 hours		**Used for short period of time because tolerance develops within 24 to 48 hours
	* [[Sodium nitroprusside]] 0.3 mcg/kg/min IV, increased up to maximum of 5 mcg/kg/min		*[[Sodium nitroprusside]] 0.3 mcg/kg/min IV, increased up to maximum of 5 mcg/kg/min
	** Preferred in [[hypertension]] or [[mitral regurgitation]]		**Preferred in [[hypertension]] or [[mitral regurgitation]]
	** Avoid in [[acute coronary syndrome]] (may cause coronary steal effect)		**Avoid in [[acute coronary syndrome]] (may cause coronary steal effect)
	** Can cause [[cyanide toxicity]]		**Can cause [[cyanide toxicity]]
	* Avoid starting new ACEi/ARB in the acute setting, but they should be started before discharge if no contraindication		*Avoid starting new ACEi/ARB in the acute setting, but they should be started before discharge if no contraindication

	=== Diuretic Therapy ===		===Diuretic Therapy===

	* [[Furosemide]]		*[[Furosemide]]
	** Moderate volume overload: 20 to 40 mg daily PO or IV		**Moderate volume overload: 20 to 40 mg daily PO or IV
	** Severe volume overload: 40 to 100 mg IV, or continuous infusion of 5 to 40 mg/h		**Severe volume overload: 40 to 100 mg IV, or continuous infusion of 5 to 40 mg/h
	* If inadequate response, can add [[hydrochlorothiazide]] 50 to 100 mg PO daily or [[spironolactone]] 25 to 50 mg daily		*If inadequate response, can add [[hydrochlorothiazide]] 50 to 100 mg PO daily or [[spironolactone]] 25 to 50 mg daily
			**Or [[metolazone]]
	* If inadequate response, consider [[dobutamine]], [[dopamine]], or dialysis		*If inadequate response, consider [[dobutamine]], [[dopamine]], or dialysis
	* Once stable, consider aldosterone antagonist (e.g. spironolactone) if LVEF ≤40% and no contraindications		*Once stable, consider aldosterone antagonist (e.g. spironolactone) if LVEF ≤40% and no contraindications

	=== β-Blockers ===		===β-Blockers===

	* Continue home β-blockers if no contraindications (e.g. hypotension or bradycardia)		*Continue home β-blockers if no contraindications (e.g. hypotension or bradycardia)
	* If no home β-blockers, add once stable		*If no home β-blockers, add once stable

	=== Supportive Treatment ===		===Supportive Treatment===

			*Position the patient upright, ideally with legs over bed to aid venous pooling and decrease preload
⚫	* Consider noninvasive positive-pressure ventilation in patients with SpO2 <90% despite supplemental oxygen
			*Supplemental oxygen by nasal prongs or face mask
	** CPAP
		⚫	*Consider noninvasive positive-pressure ventilation in patients with SpO2 <90% despite supplemental oxygen
	* May need ECMO as bridge therapy
			**CPAP preferred
			*Salt and fluid restriction
			*Daily weights: target 1kg (0.5-1.5) weight loss with 3L urine output daily
			*[[Hydromorphone]] or [[morphine]] for pain and dyspnea

	=== ~~Education~~ ===		=== Discharge ===

			* Reinforce education
	*Low-salt diet		** Low-salt diet
	*Daily weights, and logging		**Daily weights, and logging
	*Alert CHF clinic if dizzy or gained/lost 3lbs		**Alert CHF clinic if dizzy or gained/lost 3lbs
			*Document discharge weight and discharge BNP
			*Ensure β-blocker and ACEi/ARB are started, if appropriate

	[[Category:Cardiology]]		[[Category:Cardiology]]

Aidan at 01:50, 22 February 2021

2021-02-22T01:50:30Z

Show changes

Maintenance script: Imported from text file

2020-07-04T01:17:20Z

Imported from text file

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See also [[Chronic heart failure]] for non-critical care management

== Definition ==

== Causes ==

* Electrical
** Atrial fibrillation
** Complete heart block
* Myocardial
** Coronary artery disease
** Ventricular hypertrophy
** Cardiomyopathy
* Valves
** Mitral valve disease
** Aortic valve disease
* Pericardium
** Cardiac tamponade
* Large vessels
** Aortic dissection
** Severe hypertension
** Pulmonary hypertension

== Etiology ==

* Reduced ejection fraction
* Preserved ejection fraction
** Ventricular hypertrophy
** Myocardial ischemia
** Restrictive or fibrotic cardiomyopathy
** Pericardial tamponade
** Positive pressure ventilation including PEEP
* Right-sided failure
** Pulmonary hypertension from any cause, most commonly chronic lung diseases and pulmonary embolism
** Inferior wall MI

== Stages ==

# Increased filling pressures (i.e. pulmonary artery wedge pressure)
# Decreased stroke volume and increased heart rate, maintaining cardiac output
# Further increase in filling pressure and decreased cardiac output (decompensation)

== Examination ==

* History of CHF (LR+ 5.8, LR- 0.45)
* PND (LR+ 2.6)
* S3 on auscultation (LR+ 11)
* CXR showing congestion (LR+ 12)
* Atrial fibrillation (LR+ 3.8)
* No dyspnea on exertion (LR- 0.48)
* No cardiomegaly on CXR (LR- 0.33)
* Low/normal BNP (LR- 0.11)

== Management ==

* Left-sided heart failure
** High BP
*** Vasodilators with nitroglycerine, nitroprusside, or nesiritide
*** Diuretic therapy with furosemide for volume overload
** Normal BP
*** Vasodilator therapy if tolerated
*** Alternately, inodilator therapy with [[../Pharmacology/Dobutamine.md|Dobutamine]], [[../Pharmacology/Milrinone.md|Milrinone]], or levosimendan
*** Diuretic therapy with furosemide for volume overload
** Low BP
*** Inodilator therapy with [[../Pharmacology/Dobutamine.md|Dobutamine]]
*** Alternately, vasoconstrictor therapy with dopamine
*** Mechanical cardiac support
** Start ACEi 24-48h into admission, if BP and renal function allow, followed by beta blocker (if tolerated)
* Education
** Low-salt diet
** Daily weights, and logging
** Alert CHF clinic if dizzy or gained/lost 3lbs

[[Category:Cardiology]]