Acute Heart Failure

Medications (without cardiogenic shock)

 

 

-Nitroglycerin (NTG): Used to decrease preload (and afterload at higher doses), can be started as sublingual spray but should be switched to continuous infusion early (start at 30mcg/min, but may need to increase it by 10mcg/min every 10min, up to 150-200mcg/min – consider an arterial line for monitoring) -Be cautious in preload-dependent patients such as inferior MI, pulmonary hypertension and aortic stenosis 

 

 

-Furosemide (Lasix): Works by targeting kidneys, which are often poorly supplied in conditions of hypotension or catecholamine overdrive due to the splanchnic vasculature vasoconstriction -Therefore, it might be reasonable to wait for restoration of better renal perfusion while other modalities are instituted (eg, BiPAP, NTG) before using it; the patient's daily dose as an IV bolus through saline lock is a reasonable first dose, with doubling 30-60min later if no clinical effects -Use furosemide judiciously in patients with renal failure or low serum sodium: there is an association between high creatinine, furosemide use and higher long-term mortality

 

 

-Continuous infusion of furosemide as opposed to bolus therapy has been shown to reduce allcause mortality in AHF

 

 

-Morphine: Although the ADHERE registry (the largest HF registry to date) has shown worse outcomes when it is used in high doses (30-40mg), leading to increased rates of intubation and ICU admission, days of hospitalization and mortality, small doses may be considered (benzodiazepines are an alternative to decrease anxiety and the catecholamine drive)

 

 

-ACE Inhibitors: While there is evidence from small trials that SL Captopril and IV Enalapril decrease the need for intubation and rapidly improve symptoms, the 2007 Canadian Guidelines for Heart Failure suggest that they should not be used routinely; oral ACE inhibitors should be considered after the patient is stabilized, usually by the specialist at 12-24hrs after presentation

 

 

-Consider Nitroprusside in patients with a hypertensive emergency and AHF who do not respond to high doses of IV Nitroglycerin

 

 

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https://emergencymedicinecases.com/wp-content/uploads/filebase/pdf/EMC_004_May2010_Summary.pdf

https://emergencymedicinecases.com/wp-content/uploads/2021/12/Episode-163-Acute-Heart-Failure-Part-1.pdf