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


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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