Acute heart failure: Difference between revisions
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See also [[Chronic heart failure]] for non-critical care management |
See also [[Chronic heart failure]] for non-critical care management |
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− | == |
+ | ==Background== |
− | == |
+ | ===Etiologies=== |
+ | *[[Acute coronary syndrome]] |
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− | * Electrical |
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+ | *Mechanical complications of myocardial infarction |
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− | ** Atrial fibrillation |
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+ | *Acute valvular regurgitation |
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− | ** Complete heart block |
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+ | *Hypertension |
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− | * Myocardial |
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+ | *Arrhythmia including atrial fibrillation |
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− | ** Coronary artery disease |
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+ | *Peripartum cardiomyopathy |
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− | ** Ventricular hypertrophy |
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+ | *Complications of cardiac surgery |
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− | ** Cardiomyopathy |
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+ | *Infection: [[myocarditis]], [[infective endocarditis]] |
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− | * Valves |
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+ | *Endocrinopathy |
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− | ** Mitral valve disease |
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+ | *High-output heart failure: sepsis or severe infection, thyroid storm, anemia, arteriovenouss fistula, Paget disease |
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− | ** Aortic valve disease |
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+ | *Medication non-adherence |
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− | * Pericardium |
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− | ** Cardiac tamponade |
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− | * Large vessels |
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− | ** Aortic dissection |
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− | ** Severe hypertension |
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− | ** Pulmonary hypertension |
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− | == |
+ | ===Stages=== |
+ | #Increased filling pressures (i.e. pulmonary artery wedge pressure) |
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− | * Reduced ejection fraction |
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+ | #Decreased stroke volume and increased heart rate, maintaining cardiac output |
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− | * Preserved ejection fraction |
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+ | #Further increase in filling pressure and decreased cardiac output (decompensation) |
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− | ** Ventricular hypertrophy |
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− | ** Myocardial ischemia |
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− | ** Restrictive or fibrotic cardiomyopathy |
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− | ** Pericardial tamponade |
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− | ** Positive pressure ventilation including PEEP |
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− | * Right-sided failure |
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− | ** Pulmonary hypertension from any cause, most commonly chronic lung diseases and pulmonary embolism |
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− | ** Inferior wall MI |
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+ | ==Clinical Manifestations== |
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− | == Stages == |
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+ | *Hypoperfusion, with fatigue, weakness, confusion, and pale, cool, and moist extremities |
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− | # Increased filling pressures (i.e. pulmonary artery wedge pressure) |
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+ | *Circulatory congestion |
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− | # Decreased stroke volume and increased heart rate, maintaining cardiac output |
||
+ | **RV failure: peripheral edema, JV distension, epigastric tenderness from hepatomegaly, pleural or pericardial effusions |
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− | # Further increase in filling pressure and decreased cardiac output (decompensation) |
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+ | **LV failure: pulmonary edema with dyspnea, tachypnea, orthopnea, and crackles on auscultation |
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+ | *Common symptoms include progressive exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea |
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+ | {| class="wikitable" |
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− | == Examination == |
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+ | ! |
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+ | !Normal Perfusion |
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+ | !Hypoperfusion |
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+ | |- |
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+ | |Pulmonary congestion |
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+ | |warm and wet |
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+ | |cold and wet |
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+ | |- |
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+ | |No pulmonary congestion |
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+ | |warm and dry |
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+ | |cold and dry |
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+ | |} |
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+ | ===Rational Clinical Examination=== |
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− | * History of CHF (LR+ 5.8, LR- 0.45) |
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+ | {| class="wikitable sortable" |
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− | * PND (LR+ 2.6) |
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+ | !Sign or Symptom |
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− | * S3 on auscultation (LR+ 11) |
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+ | !LR+ |
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− | * CXR showing congestion (LR+ 12) |
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+ | !LR– |
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− | * Atrial fibrillation (LR+ 3.8) |
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+ | |- |
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− | * No dyspnea on exertion (LR- 0.48) |
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+ | |CXR showing congestion |
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− | * No cardiomegaly on CXR (LR- 0.33) |
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+ | |12 |
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− | * Low/normal BNP (LR- 0.11) |
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+ | | |
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+ | |- |
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+ | |S3 on auscultation |
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+ | |11 |
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+ | | |
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+ | |- |
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+ | |History of heart failure |
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+ | |5.8 |
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+ | |0.45 |
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+ | |- |
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+ | |Atrial fibrillation |
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+ | |3.8 |
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+ | | |
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+ | |- |
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+ | |Paroxysmal nocturnal dyspnea |
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+ | |2.6 |
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+ | | |
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+ | |- |
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+ | |No dyspnea on exertion |
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+ | | |
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+ | |0.48 |
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+ | |- |
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+ | |No cardiomegaly on CXR |
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+ | | |
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+ | |0.33 |
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+ | |- |
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+ | |Low or normal BNP |
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+ | | |
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+ | |0.11 |
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+ | |} |
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− | == |
+ | ==Investigations== |
+ | *ECG to assess for [[myocardial infarction]], [[arrhythmia]], and [[conduction abnormalities]] |
||
− | * Left-sided heart failure |
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+ | *Chest x-ray for evidence of pulmonary congestion, pleural effusion, or cardiomegaly |
||
− | ** High BP |
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+ | *Echocardiography |
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− | *** Vasodilators with nitroglycerine, nitroprusside, or nesiritide |
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+ | *Laboratory tests |
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− | *** Diuretic therapy with furosemide for volume overload |
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+ | **Routine, including CBC, creatinine, electrolytes, liver enzymes, ± ABG |
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− | ** Normal BP |
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+ | **Cardiac-specific, including troponin and BNP/NT-proBNP |
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− | *** Vasodilator therapy if tolerated |
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+ | |||
− | *** Alternately, inodilator therapy with [[../Pharmacology/Dobutamine.md|Dobutamine]], [[../Pharmacology/Milrinone.md|Milrinone]], or levosimendan |
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+ | ==Management== |
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− | *** Diuretic therapy with furosemide for volume overload |
||
+ | |||
− | ** Low BP |
||
+ | *Treat underlying condition and acute precipitant |
||
− | *** Inodilator therapy with [[../Pharmacology/Dobutamine.md|Dobutamine]] |
||
+ | *Continue home β-blocker and ACEi/ARB unless hypotensive or bradycardic |
||
− | *** Alternately, vasoconstrictor therapy with dopamine |
||
+ | *Left-sided heart failure with reduced ejection fraction |
||
− | *** Mechanical cardiac support |
||
+ | **Managed primarily with vasodilators, loop diuretics, and mechanical ventilation |
||
− | ** Start ACEi 24-48h into admission, if BP and renal function allow, followed by beta blocker (if tolerated) |
||
+ | **High BP |
||
− | * Education |
||
+ | ***Vasodilators with [[nitroglycerine]], [[nitroprusside]], or [[nesiritide]] |
||
− | ** Low-salt diet |
||
+ | ***Diuretic therapy with [[furosemide]] for volume overload |
||
− | ** Daily weights, and logging |
||
+ | **Normal BP |
||
− | ** Alert CHF clinic if dizzy or gained/lost 3lbs |
||
+ | ***Vasodilator therapy if tolerated (avoid if SBP less than 110 mmHg) |
||
+ | ***Alternately, inodilator therapy with [[dobutamine]], [[milrinone]], or [[levosimendan]] |
||
+ | ***Diuretic therapy with [[furosemide]] for volume overload |
||
+ | **Low BP |
||
+ | ***Inodilator therapy with [[dobutamine]] |
||
+ | ***Alternately, vasoconstrictor therapy with [[dopamine]] |
||
+ | ***Mechanical cardiac support |
||
+ | **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 |
||
+ | **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 |
||
+ | **Avoid vasodilators (including ACEi/ARBs) and diuretics |
||
+ | **May need careful fluid administration to improve cardiac output |
||
+ | **Occasionally need [[dopamine]] |
||
+ | |||
+ | ===Vasodilators=== |
||
+ | |||
+ | *[[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 |
||
+ | **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 |
||
+ | *[[Sodium nitroprusside]] 0.3 mcg/kg/min IV, increased up to maximum of 5 mcg/kg/min |
||
+ | **Preferred in [[hypertension]] or [[mitral regurgitation]] |
||
+ | **Avoid in [[acute coronary syndrome]] (may cause coronary steal effect) |
||
+ | **Can cause [[cyanide toxicity]] |
||
+ | *Avoid starting new ACEi/ARB in the acute setting, but they should be started before discharge if no contraindication |
||
+ | |||
+ | ===Diuretic Therapy=== |
||
+ | |||
+ | *[[Furosemide]] |
||
+ | **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 |
||
+ | *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 |
||
+ | *Once stable, consider aldosterone antagonist (e.g. spironolactone) if LVEF ≤40% and no contraindications |
||
+ | |||
+ | ===β-Blockers=== |
||
+ | |||
+ | *Continue home β-blockers if no contraindications (e.g. hypotension or bradycardia) |
||
+ | *If no home β-blockers, add once stable |
||
+ | |||
+ | ===Supportive Treatment=== |
||
+ | |||
+ | *Position the patient upright, ideally with legs over bed to aid venous pooling and decrease preload |
||
+ | *Supplemental oxygen by nasal prongs or face mask |
||
+ | *Consider noninvasive positive-pressure ventilation in patients with SpO2 <90% despite supplemental oxygen |
||
+ | **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 |
||
+ | |||
+ | ===Discharge=== |
||
+ | |||
+ | *Reinforce education |
||
+ | **Low-salt diet |
||
+ | **Daily weights, and logging |
||
+ | **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 |
||
+ | *See also [[Chronic heart failure#Management|Chronic heart failure]] |
||
[[Category:Cardiology]] |
[[Category:Cardiology]] |
Latest revision as of 13:31, 14 October 2021
See also Chronic heart failure for non-critical care management
Background
Etiologies
- Acute coronary syndrome
- Mechanical complications of myocardial infarction
- Acute valvular regurgitation
- Hypertension
- Arrhythmia including atrial fibrillation
- Peripartum cardiomyopathy
- Complications of cardiac surgery
- Infection: myocarditis, infective endocarditis
- Endocrinopathy
- High-output heart failure: sepsis or severe infection, thyroid storm, anemia, arteriovenouss fistula, Paget disease
- Medication non-adherence
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)
Clinical Manifestations
- Hypoperfusion, with fatigue, weakness, confusion, and pale, cool, and moist extremities
- Circulatory congestion
- 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
- Common symptoms include progressive exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea
Normal Perfusion | Hypoperfusion | |
---|---|---|
Pulmonary congestion | warm and wet | cold and wet |
No pulmonary congestion | warm and dry | cold and dry |
Rational Clinical Examination
Sign or Symptom | LR+ | LR– |
---|---|---|
CXR showing congestion | 12 | |
S3 on auscultation | 11 | |
History of heart failure | 5.8 | 0.45 |
Atrial fibrillation | 3.8 | |
Paroxysmal nocturnal dyspnea | 2.6 | |
No dyspnea on exertion | 0.48 | |
No cardiomegaly on CXR | 0.33 | |
Low or normal BNP | 0.11 |
Investigations
- ECG to assess for myocardial infarction, arrhythmia, and conduction abnormalities
- Chest x-ray for evidence of pulmonary congestion, pleural effusion, or cardiomegaly
- Echocardiography
- Laboratory tests
- Routine, including CBC, creatinine, electrolytes, liver enzymes, ± ABG
- Cardiac-specific, including troponin and BNP/NT-proBNP
Management
- Treat underlying condition and acute precipitant
- Continue home β-blocker and ACEi/ARB unless hypotensive or bradycardic
- Left-sided heart failure with reduced ejection fraction
- Managed primarily with vasodilators, loop diuretics, and mechanical ventilation
- High BP
- Vasodilators with nitroglycerine, nitroprusside, or nesiritide
- Diuretic therapy with furosemide for volume overload
- Normal BP
- Vasodilator therapy if tolerated (avoid if SBP less than 110 mmHg)
- Alternately, inodilator therapy with dobutamine, milrinone, or levosimendan
- Diuretic therapy with furosemide for volume overload
- Low BP
- Inodilator therapy with dobutamine
- Alternately, vasoconstrictor therapy with dopamine
- Mechanical cardiac support
- 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
- 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
- Avoid vasodilators (including ACEi/ARBs) and diuretics
- May need careful fluid administration to improve cardiac output
- Occasionally need dopamine
Vasodilators
- 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
- 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
- Sodium nitroprusside 0.3 mcg/kg/min IV, increased up to maximum of 5 mcg/kg/min
- Preferred in hypertension or mitral regurgitation
- Avoid in acute coronary syndrome (may cause coronary steal effect)
- Can cause cyanide toxicity
- Avoid starting new ACEi/ARB in the acute setting, but they should be started before discharge if no contraindication
Diuretic Therapy
- Furosemide
- 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
- 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
- Once stable, consider aldosterone antagonist (e.g. spironolactone) if LVEF ≤40% and no contraindications
β-Blockers
- Continue home β-blockers if no contraindications (e.g. hypotension or bradycardia)
- If no home β-blockers, add once stable
Supportive Treatment
- Position the patient upright, ideally with legs over bed to aid venous pooling and decrease preload
- Supplemental oxygen by nasal prongs or face mask
- Consider noninvasive positive-pressure ventilation in patients with SpO2 <90% despite supplemental oxygen
- 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
Discharge
- Reinforce education
- Low-salt diet
- Daily weights, and logging
- 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
- See also Chronic heart failure