Severe Heart Failure Management

OVERVIEW

• preload reduction: diuretics, opioids, decrease intake, spironolactone
• afterload reduction: ACE-I, GTN, IABP
• increase contractility: milrinone, dobutamine, adrenaline, VAD
• decreased myocardial work: beta-blockers, IABP, VAD
• increased coronary perfusion and oxygenation: O2, Hb, Stents, CABG, IABP

bold = evidence for decreased mortality

ACUTE MEDICAL THERAPY

• sit patient up
• high flow O2
• nitrates (IV, SL, TOP) if not hypotensive (consider SNP)
• NIV +/- intubation
• urinary catheter
• DVT prophylaxis (MEDENOX study -> significant decrease in DVT with enoxaparin)
• inotropes (often used as a bridge to transplant or revascularisation)
• diuretics if evidence of fluid overload (relief of symptoms, no survival advantage)
• avoid opioids (may decrease WOB and temporarily decreases cardiac preload but higher rates of intubation)

Consider

• IABP (some data to suggest lower rate of mortality if used early)
• nesiritide (recombinant human BNP -> diuresis, reduces pre and afterload, reduces ventricular remodelling and fibrosis -> being investigated)
• VAD or ECMO (e.g. transient cause, bridge to transplant)

ASSISTED VENTILATION

• CPAP: favourable effects on intrathoracic and left ventricular transmural pressure
  -> significant reduction in mortality and intubation rates
• BIPAP: reduction in intubation, trend to reduction in mortality
• invasive ventilation: associated with poor prognosis but can produce dramatic improvement

CHRONIC TREATMENT

• loop diuretics (symptomatic relief, no mortality benefit)
• ACE-Is and ATII-R blockers (improved mortality and hospital admission)
• beta-blockers (mortality reduction)
• aldosterone inhibitors – spirinolactone (marked mortality reduction)
• anticoagulation for very low ejection fraction or AF
• digoxin (no mortality advantage)
• biventricular pacing (may benefit some patients)
• AF: rate control with digoxin, amiodarone and beta-blockers + anticoagulate
• ventricular arrhythmias: ICD may be indicated

INVASIVE INTERVENTIONS

• may require urgent surgery for acute MR or AR with APO
• LVAD: may be used as a bridge or for those not eligible for transplant (mortality reduction apparent but there are major complications)
• revascularisation: patients with cardiogenic shock do better with revascularisation

References and Links

• Wiesbauer F. Medical Treatment of Heart Failure. Medmastery
• EMCrit Podcast 1 – Sympathetic Crashing Acute Pulmonary Edema
• EMCrit — When to wean the CPAP in SCAPE
• EMCrit Podcast 10 – Cardiogenic Shock