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Emergency Medicine: Cardiology 213

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  1. Acute Coronary Syndromes: A Focus on STEMI
    10 Topics
    3 Quizzes
  2. Acute decompensated heart failure
    10 Topics
    3 Quizzes
  3. Hypertensive Urgency and Emergency Management
    11 Topics
    3 Quizzes
  4. Acute aortic dissection
    9 Topics
    2 Quizzes
  5. Arrhythmias (Afib, SVT, VTach)
    10 Topics
    2 Quizzes

Participants 220

  • April
  • Alyssa
  • Ashley
  • Amber
  • Sherif
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The choice of pharmacologic agents depends on the patient’s hemodynamic profile:

Warm and Dry: (CI greater than 2.2 L + PCWP less than 18 mm Hg)

  • Focus on optimizing chronic oral heart failure therapies
    • Initiate/uptitrate beta-blockers (e.g. carvedilol, metoprolol succinate) and ACE inhibitors or ARBs (e.g. lisinopril, losartan) as tolerated
    • Add hydralazine and nitrates (e.g. isosorbide dinitrate) in African American patients
    • Consider adding angiotensin receptor-neprilysin inhibitor (sacubitril/valsartan) for HFrEF if tolerated
    • Continue other oral therapies (digoxin, loop diuretics) if previously prescribed

Warm and Wet: Without Flash Pulmonary Edema (CI> 2.2 L + PCWP greater than 18 mm Hg)

  • Intravenous loop diuretics (furosemide 20-40 mg IV or bumetanide 1-2 mg IV)
  • Double patients’ oral daily loop diuretic dose for initial IV dose
  • If oral loop diuretic naive, start furosemide 40 mg IV daily or bumetanide 2 mg IV daily
  • Monitor urine output, symptoms, weight loss
  • Repeat doses every 2 hours as needed
  • For diuretic resistance:
    • Increase loop diuretic dose
    • Add metolazone 2.5-10 mg oral daily
    • Switch to continuous infusion loop diuretic
    • Consider ultrafiltration
  • Add intravenous nitroglycerin infusion if persistent symptoms, start at 5-10 mcg/min, titrate by 5-10 mcg/min every 5 minutes, max 200 mcg/min
  • For hypertensive patients, sodium nitroprusside 0.3-5 mcg/kg/min IV is an alternative to nitroglycerin

Warm and Wet: Flash Pulmonary Edema (CI> 2.2 L + PCWP greater than 18 mm Hg)

A subset of warm and wet profile patients present with flash pulmonary edema, characterized by:

  • Abrupt onset dyspnea and hypoxemia
  • Pink, frothy sputum
  • Hypertensive crisis (SBP > 180 mmHg)
  • Bilateral pulmonary rales

Management should focus on rapid symptom relief:

  • High dose intravenous nitroglycerin
    • Options:
      • Intravenous bolus of 2000 mcg every 3-5 minutes as needed
      • Intravenous infusion at 100-200 mcg/min
    • Titrate to relief of dyspnea and oxygenation improvement
    • Wean infusion as symptoms and blood pressure improve
  • Non-invasive positive pressure ventilation
  • Consider intravenous enalaprilat 0.625-1.25 mg if blood pressure remains elevated after nitroglycerin
  • Cautious use of intravenous furosemide 20-40 mg to relieve fluid overload after stabilization with above measures

Cold and Dry:(CI less than 2.2 L + PCWP less than 18 mm Hg)

  • Assess PCWP
    •  If <15 mm Hg, administer IVF
    • If 15-18 mm Hg, assess for systemic hypotension
      •  Mean arterial pressure (MAP):  2/3 DBP + 1/3 SBP
  • Cautious intravenous fluids 250-500 mL to increase preload
  • Consider holding loop diuretics temporarily
  • Inotropes if fluid bolus insufficient:
    • Dobutamine 2-20 mcg/kg/min IV
    • Milrinone 0.375-0.75 mcg/kg/min IV
      • Small trials directly comparing these agents in ADHF have resulted in no difference in clinical outcomes
  • Titrate to target CI > 2.2 L/min/m2 and MAP > 65 mmHg
  • Add norepinephrine if MAP remains low after inotrope initiation

Cold and Wet: (CI less than 2.2 L + PCWP greater than 18 mm Hg)

  • Intravenous loop diuretics as above to relieve congestion
  • Inotropes as above to improve cardiac output
  • Vasopressors if inotropes cause hypotension:
    • Norepinephrine 0.2-1 mcg/kg/min IV
    • Dopamine 2-10 mcg/kg/min IV
  • Target CI > 2.2 L/min/m2, MAP > 65 mmHg, PCWP 15-18 mmHg
  • Consider mechanical circulatory support if refractory

Loop Diuretics

  • Furosemide, bumetanide are first-line
  • Initiate with IV bolus or infusion at 1-2.5 times oral dose
  • Adjust dose based on urine output, weight loss, symptoms
  • Monitor electrolytes, renal function
  • Overcoming Resistance
    • Increase loop diuretic dose
    • Add thiazide diuretic (e.g. metolazone, chlorothiazide)
    • Switch to continuous infusion
    • Consider ultrafiltration

Nonpharmacologic Therapies

  • Sodium restriction
  • Ultrafiltration for diuretic resistance
  • Temporary mechanical circulatory support (MCS) for refractory ADHF
  • Durable MCS or cardiac transplantation in advanced heart failure

Evaluation of Therapeutic Outcomes

  • Monitor symptoms, vital signs, orthostasis, weights, electrolytes, renal function
  • Assess response to intravenous therapies
  • Prepare for discharge once euvolemic and stable on oral agents
  • Initiate/optimize guideline-directed medical therapies prior to discharge
  • Schedule prompt follow-up appointment and testing after discharge