Heart Failure is a clinical syndrome characterized by typical symptoms (e.g. breathlessness, ankle swelling and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles and peripheral oedema) caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress23.
Acute Heart Failure (AHF) or Decompensated Acute Heart Failure (ADHF)
AHF is defined as rapid or gradual onset of signs and symptoms of heart failure that results in urgent unplanned hospitalization or Emergency Medicine Department visits. The clinical signs and symptoms are significantly life threatening if the above features occur in patients with established diagnosis with structurally heart disease categorized as Acute Decompensated Heart Failure (ADHF)2. The cause and immediate precipitating factor(s) of the AHF must be identified and treated to prevent further damage to the heart.
Treatment Goals
To improve clinical symptoms and outcome, management strategy should be based on clinical, laboratory and haemodynamic findings. All patient with AHF should be cared and admitted to a high care dependent unit or Intensive Care Unit.
Non-Pharmacological Treatment:
Oxygen therapy and/or ventilatory support.
Ventilatory support:
- Non-invasive positive pressure ventilation includes both CPAP and bi–level positive pressure ventilation (PPV)
- Mechanical ventilation
Note: In AHF, oxygen should not be used routinely in non–hypoxaemic patients, as it causes vasoconstriction and a reduction in cardiac output
Pharmacological treatment
Recommendations for the management of patients with acute heart failure:
Diuretics
Diuretics are a cornerstone in the treatment of patients with AHF and signs of fluid overload and congestion. Improve congestive symptoms. It is recommended to regularly monitor symptoms, urine output, renal function and electrolytes during use of intravenous diuretics
In patients with new-onset AHF or those with chronic, decompensated HF not receiving oral diuretics the initial recommended dose should be 20–40 mg intravenous furosemide (or equivalent); for those on chronic diuretic therapy, initial intravenous dose should be at least equivalent to oral dose
It is recommended to give diuretics either as intermittent boluses or as a continuous infusion, and the dose and duration should be adjusted according to patients’ symptoms and clinical status. Combination of loop diuretic with either thiazide-type diuretic or spironolactone may be considered
Loop diuretic
B: Furosemide 20–120mg I.V
OR
S: Torsemide 5–20mg orally
Plus
Mineralocorticoid (Aldosterone) Receptor Antagonists:
C: Spironolactone 25–50mg
OR
S: Eplerenone 25–50mg orally
Vasodilators: these are the cornerstone of treatment of AHF and have dual benefit by decreasing venous tone (to optimize preload) and arterial tone (decrease afterload). Consequently, they increase stroke volume
Intravenous vasodilators should be considered for symptomatic relief in AHF with SBP >90 mmHg (and without symptomatic hypotension). Symptoms and blood pressure should be monitored frequently during administration of intravenous vasodilators. In patients with hypertensive AHF, intravenous vasodilators should be considered as initial therapy to improve symptoms and reduce congestion. Intravenous vasodilators for treating AHF are described in table 20.3.
Table 20.5: Intravenous Vasodilators, dose and side effects.
Note: Vasodilators should be used with caution in patients with significant mitral or aortic stenosis
| Vasodilator | Dosing | Mainside effects | Other |
| Nitroglycerine | Start with 10–20µg/min, increase up to 200 µg/min | Hypotension, headache | Tolerance on continuous use |
| Isosorbide dinitrate | Start with 1mg/h, increase up to 10mg/h | Hypotension, headache | Tolerance on continuous use |
| Nitroprusside | Start with 0.3 µg/kg/min and increase up to5µg/kg/min | Hypotension, isocyanate toxicity | Light sensitive |
Consider oral vasodilators in case intravenous vasodilator not available or unavailability of intensive care or high dependent unit care
C: Isosorbide mononitrate 10–20mg (PO) 12 hourly
OR
C: Hydralazine 25 mg (PO) 6–8 hourly. Maximum dose: 200 mg/day
Inotropes (Inotropic agents)
Indicated in patients with hypotension (SBP <90 mmHg or mean arterial BP < 60mmHg) and peripheral hypoperfusion. Dosage see below table 20.4
Vasopressor (norepinephrine preferably) Indicated in patients with cardiogenic shock, despite treatment with another inotrope, to increase blood pressure and vital organ perfusion. Dosage: see table 20.4
Indication: Patients with cardiogenic shock, despite treatment with another inotrope, to increase blood pressure and vital organ perfusion.
Table 20.6: Positive inotropes and/or vasopressors for treat acute heart failure
| Inotropes/Vasopressors | Bolus | Infusion rate |
| Dobutamine | No | 2–20µg/kg/min(beta+) |
| Dopamine | No | 3–5 µg/kg/min; inotropic(beta+)
>5 µg/kg/min:(beta+), vasopressor(alpha+) |
| Norepinephrine | No | 0.2–1.0µg/kg/min |
| Epinephrine | Bolus:1mg can be given iv during resuscitation, Repeated every 3–5 min | 0.05–0.5µg/kg/min |
Special pharmacological treatment consideration:
Add ACEI
B: Captopril 6.25–25mg (PO) three times a day
OR
C: Enalapril 5–20mg (PO) twice a day. When patient is out of congestive state and renal failure
Add Beta-blocker
C: Carvedilolol 6.25–25mg twice a day especially in heart failure with reduced systolic function
When patient is out of congestive state and SBP above 90mmHg and In case patient admitted with beta blocker continue with carvedilol unless is contraindicated
Thrombo–embolism prophylaxis
Thrombo–embolism prophylaxis (LMWH) is recommended in patients not already anticoagulated and with no contra indication to anticoagulation, to reduce the risk of deep venous thrombosis and pulmonary embolism.
D: Unfractionated heparin 5,000u subcutaneous twice a day
OR
D: Low molecular weight heparin–Enoxaparin 40mg–80mg subcutaneous twice a day
Referral
All patients with AHF should be treated at centre/hospital where at least can perform Echocardiographic assessment and Intensive Care Units (ICU) or High care dependent Units (HDUs) are available
