Lesson 2, Topic 6
The priorities in management include:
- Respiratory support
- Hemodynamic stabilization
- Congestion relief
- Restoration of adequate perfusion
- Limiting organ injury
- Monitoring for arrhythmias
- Planning hospital discharge and follow-up
- Relief of congestive symptoms
- Restoration of adequate end-organ perfusion
- Optimization of volume status and hemodynamic stability
- Minimization of further cardiac damage and adverse drug reactions
- Appropriate initiation/titration of guideline-directed medical therapies
- Discontinue medications worsening heart failure (e.g. NSAIDs, thiazolidinediones)
- Initiate intravenous loop diuretics for congestion, using 1-2.5 times oral dose
- Continue beta-blockers and other guideline-directed medical therapies if possible
- Select additional therapies based on hemodynamic profile
- Diuretics: Loop diuretics (e.g. furosemide, bumetanide) are first-line for volume overload. May need combination with thiazide diuretics for diuretic resistance.
- Vasodilators: Nitroglycerin, nitroprusside – Used for rapid symptom relief in hypertensive ADHF with pulmonary edema.
- Hemodynamic effects: ↓ PCWP, ↓ SVR, ↓ MAP, ↑ CO
- Inotropes: Dobutamine, milrinone – Reserved for cardiogenic shock refractory to other measures. Increase contractility and cardiac output.
- Vasopressors: Norepinephrine, dopamine – Used in conjunction with inotropes for hypotensive shock with low blood pressure.
- Other agents: Morphine avoided due to risks. Vasopressin antagonists used for severe hyponatremia.
- Oxygenation/ventilation support
- Ultrafiltration for diuretic resistance
- Mechanical circulatory support devices in refractory shock
- Cardiac transplantation or left ventricular assist devices in advanced heart failure
|Subset I: “Warm and Dry”: Optimize PO heart failure regimen||GOAL|
|Subset II: “Warm and Wet”: Provide symptomatic relief from congestion||DIURETIC|
|Subset III: “Cold and Dry”: Increase perfusion to vital organs to alleviate symptoms||FLUIDS|
|Subset IV: “Cold and Wet”: Alleviate congestion and hypoperfusion||INOTROPE OR VASOPRESSOR + DIURETIC|