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ALL / Cardiology

Heart failure: acute management

Heart failure: acute management

Recommended treatments for all patients
  • IV loop diuretics
    • e.g. furosemide or bumetanide
    • NICE recommend using a higher dose of diuretic than that on which the person was admitted

Possible additional treatments
  • oxygen
    • this should be given in line with British Thoracic Society guidelines, i.e. keep oxygen saturations at 94-98%
  • vasodilators
    • e.g. IV GTN, isosorbide dinitrate or sodium nitroprusside infusion
    • reduce preload and afterload
    • nitrates should not be routinely given to all patients, may be considered if systolic BP > 100 mmHg
    • they may, however, have a role if concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease
    • the major side-effect/contraindication is hypotension

Chest x-ray showing pulmonary oedema - e Image used on license from Radiopaedia

Patients with respiratory failure
  • CPAP

Patients with hypotension (e.g. < 85 mmHg)/cardiogenic shock
  • this can be a difficult scenario to manage
    • some of the treatments typically used for acute heart failure (e.g. loop diuretics and nitrates) may exacerbate the hypotension
  • inotropic agents
    • e.g. dobutamine
    • should be considered for patients with severe left ventricular dysfunction who have potentially reversible cardiogenic shock
  • vasopressor agents
    • e.g. norepinephrine
    • normally only used if insufficient response to inotropes and evidence of end-organ hypoperfusion
  • mechanical circulatory assistance
    • e.g. intra-aortic balloon counterpulsation or ventricular assist devices

Other treatments
  • opiates
    • NICE state 'do not routinely offer opiates to people with acute heart failure'
    • they were previously used routinely and help to reduce dyspnoea/distress in patients
    • however some studies have suggested increased morbidity in patients given opiates

General points
  • regular medication for heart failure such as beta-blockers ACE-inhibitors should be continued
    • beta-blockers should only be stopped if the patient has heart rate less than 50 beats per minute, second or third degree atrioventricular block, or shock
+PassMedicine Notes
Recommended treatments for all patients
  • IV loop diuretics
    • e.g. furosemide or bumetanide
    • NICE recommend using a higher dose of diuretic than that on which the person was admitted
Possible additional treatments
  • oxygen
    • this should be given in line with British Thoracic Society guidelines, i.e. keep oxygen saturations at 94-98%
  • vasodilators
    • e.g. IV GTN, isosorbide dinitrate or sodium nitroprusside infusion
    • reduce preload and afterload
    • nitrates should not be routinely given to all patients, may be considered if systolic BP > 100 mmHg
    • they may, however, have a role if concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease
    • the major side-effect/contraindication is hypotension
Patients with respiratory failure
  • CPAP
Patients with hypotension (e.g. < 85 mmHg)/cardiogenic shock
  • this can be a difficult scenario to manage
    • some of the treatments typically used for acute heart failure (e.g. loop diuretics and nitrates) may exacerbate the hypotension
  • inotropic agents
    • e.g. dobutamine
    • should be considered for patients with severe left ventricular dysfunction who have potentially reversible cardiogenic shock
  • vasopressor agents
    • e.g. norepinephrine
    • normally only used if insufficient response to inotropes and evidence of end-organ hypoperfusion
  • mechanical circulatory assistance
    • e.g. intra-aortic balloon counterpulsation or ventricular assist devices
Other treatments
  • opiates
    • NICE state 'do not routinely offer opiates to people with acute heart failure'
    • they were previously used routinely and help to reduce dyspnoea/distress in patients
    • however some studies have suggested increased morbidity in patients given opiates
General points
  • regular medication for heart failure such as beta-blockers ACE-inhibitors should be continued
    • beta-blockers should only be stopped if the patient has heart rate less than 50 beats per minute, second or third degree atrioventricular block, or shock


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