Heart Failure is a clinical syndrome characterized by typical symptoms that may be accompanied by signs caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress.

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.

Furosemide 20–120mg I.V

OR

Torsemide 5–20mg orally Plus Mineralocorticoid (Aldosterone)

Receptor Antagonists:

Spironolactone 25–50mg

OR

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), please refers to image 1 above. 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. Please see image number 1 above

Consider oral vasodilators in case intravenous vasodilator not available or unavailability of intensive care or high dependent unit care

Isosorbide mononitrate 10–20mg (PO) 12 hourly

OR

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 image number 2 above

Vasopressor (norepinephrine preferably) Indicated in patients with cardiogenic shock, despite treatment with another inotrope, to increase blood pressure and vital organ perfusion. Dosage: see image number 2 above

Indication: Patients with cardiogenic shock, despite treatment with another inotrope, to increase

Blood pressure and vital organ perfusion.

Special pharmacological treatment consideration:

Add ACEI

Captopril 6.25–25mg (PO) three times a day

OR

Enalapril 5–20mg (PO) twice a day.

When patient is out of congestive state and renal failure

Add Beta-blocker

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.

Unfractionated heparin 5,000u subcutaneous twice a day

OR

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.

Non pharmacological

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