Acute heart failure

See also Chronic heart failure for non-critical care management

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

1. Increased filling pressures (i.e. pulmonary artery wedge pressure)
2. Decreased stroke volume and increased heart rate, maintaining cardiac output
3. 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