image by: Heart Failure Aware
It is critical to remember that the traditional teaching that patients in CHF are fluid-overloaded is not accurate for this situation. They are fluid-overloaded in their lungs but not total body... what you need to do is treat with nitroglycerin first. Also, non-invasive positive pressure ventilation (NIPPV) is key.
The combination will reduce preload, reduce afterload, and help with LV dysfunction in such patients. Decreasing preload will decrease RV output to an amount that the LV can handle which improves the fluid backup. Decreasing afterload also improves LV output. All of this has helped reduce the need for intubation in these sick patients... When it comes to nitrates, the…
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Heart failure is a deadly disease that requires an understanding of the pathophysiology and diagnostic modalities to properly treat. Most HF patients will require diuresis; however, the sickest HF patients will require aggressive, focused care.
Management of acute heart failure without cardiogenic shock: Oxygenation, nitroglycerin, diuresis and treating the underlying cause.
The vast majority of patients presenting with AHF fall into the warm and wet category. Mainstay of treatment for these patients is diuresis. Start with their home dose of furosemide IV.
Emergency department management and appropriate interventions are discussed, along with critical decision-making points in resuscitation for both hypertensive and hypotensive patients.
Heart failure is a hugely common problem and when patients present in Acute Heart Failure (AHF) they can be BIG sick.
It can be easy to think of the term AHF as an ultimate diagnosis, but getting upper in and a really good grip on the physiology leading to the failure of the cardiovascular system mean we can really tailor evaluation and treatment to the specific area our patients are suffering with.
Although the authors conclude early treatment with IV loop diuretics is associated with lower in-hospital mortality, it is important to remember, patients in the early treatment group were more likely to arrive by ambulance, have an onset of symptoms that was more abrupt, and have more obvious signs of volume overload.
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.
The use of IV morphine in ADHF is associated with increased morbidity and mortality and should be abandoned completely as a “first-line” medical therapy. If you want to decrease diastolic filling pressures in ADHF from venous pooling just use nitroglycerin.
Though we see HF daily and there are several sets of guidelines available,8-12 there are several myths and misconceptions in HF evaluation and management.
A variety of misconceptions are present concerning the ED evaluation and management of AHF Patients with hypertensive pulmonary edema require nitroglycerin and NIPPV. Diuretics before these therapies can be harmful.
A description of recommended treatment for CHF from 1966...
Today, we take a deep dive into the classification and etiology of decompensated CHF to better understand the disease process. And then a short review on the basics of management just go through it systematically.
To boil it down to 10 seconds:
Start patient on Non-invasive ventilation with a PEEP of 6-8; quickly titrate to a PEEP of 10-15.
Start the patient on a nitroglycerin drip. Administer a loading dose of 4oo mcg/min for 2 minutes (120 ml/hour on the pump for 2 minutes with the standard nitro concentration of 200 mcg/ml.) Then drop the dose to 100 mcg/min and titrate it up from there as needed.
By 10 minutes, your patient should be out of the water.
Acutely decompensated CHF can be a highly dangerous condition and one that needs immediate management.
Treatment Principles (Acute and Chronic):
Preload reduction: Diuretics, Nitroglycerin, Restrict fluid/sodium.
Afterload reduction: ACE-I, Nitroglycerin, Intra-aortic Balloon Pump (IABP).
Increase contractility: Milrinone, Dobutamine, Ventricular Assist Device (VAD).
Decrease myocardial work: Beta-blockers, Ivabradine, IABP, VAD.
Increase coronary perfusion: Stents, CABG, IABP.
Consider Non-invasive Positive Pressure Ventilation (NIPPV) in setting of respiratory distress, hypercapnia or persistent hypoxia despite supplemental O2.
Assume valvular problem in new-onset CHF.
Assume valve thrombosis in CHF with a prosthetic valve.
Do not give vasodilators in aortic stenosis, HOCM; yes in mitral regurgitation.