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.

• A: Furosemide IV 20–120 mg every 24 hours.

• Children: IM/IV bolus 1–2 mg/kg/dose every 6–8 hours, increased by 1–2 mg/kg/dose every 6–8 hours (maximum 6 mg/kg/dose); IV infusion 0.1–0.4 mg/kg/hour.

OR

Torsemide 5–20mg orally Plus

Mineralocorticoid (Aldosterone) Receptor Antagonists:

• C: Spironolactone 25–50 mg PO every 24 hours. Children: 1–3 mg/kg/day PO divided every 12 hours.

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

Consider IV vasodilators for symptom relief in AHF with SBP above 90 mmHg and no symptomatic hypotension; monitor symptoms and BP often. In hypertensive AHF use them as initial therapy to relieve symptoms and congestion. Use with caution in significant mitral or aortic stenosis.

• S: Nitroglycerin (glyceryl trinitrate) IV infusion, start 5–10 micrograms/minute and increase as needed (up to more than 200 micrograms/minute) – dose from the hypertensive emergency section of STG 2026.

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

C: Isosorbide dinitrate 10–20 mg PO every 12 hours

OR

• B: Hydralazine 25 mg PO every 6–8 hours, maximum 200 mg/24 hours.

• Children: PO 0.75–3 mg/kg/day divided every 6–12 hours; IV 0.1–0.5 mg/kg/dose every 6–8 hours (maximum 2 mg/kg/dose).

Inotropes (Inotropic agents)

Inotropes are indicated in hypotension (SBP below 90 mmHg or mean arterial pressure below 60 mmHg) with peripheral hypoperfusion.

Other inotropes: D: digoxin injection 0.25 mg/ml or tablets 0.125–0.25 mg; children digoxin PO 10–15 micrograms/kg/day divided every 12 hours.

Vasopressor (norepinephrine preferred, infusion 0.2–1.0 micrograms/kg/minute): for cardiogenic shock despite another inotrope, to raise blood pressure and vital organ perfusion.

Indication: Patients with cardiogenic shock, despite treatment with another inotrope, to increase blood pressure and vital organ perfusion.

Special pharmacological treatment consideration:

Add ACEI

B: Captopril 6.25–25 mg PO every 8 hours. Children: 0.3–0.6 mg/kg/dose every 6–12 hours (maximum 6 mg/kg/day).

OR

C: Enalapril 5–20 mg PO every 12 hours. Children: 0.08 mg/kg/day once daily or divided every 12 hours (maximum 5 mg).

OR C: lisinopril 5–10 mg PO every 24 hours. Children: 0.07 mg/kg/day (maximum 5 mg/day).

When patient is out of congestive state and renal failure

Add Beta-blocker

C: Carvedilol 6.25–25 mg PO every 12 hours, especially in heart failure with reduced systolic function. Children: 0.03–0.08 mg/kg/dose every 12 hours.

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.

C: Unfractionated heparin 5,000 IU SC every 12 hours. Children: IV bolus 50–100 IU/kg, then IV infusion 20 IU/kg/hour.

OR

D: Low molecular weight heparin (enoxaparin) 40–80 mg SC every 12 hours. Children (prophylaxis): under 2 months 0.75 mg/kg SC every 12 hours; 2 months or older 0.5 mg/kg SC every 12 hours.

OR S: rivaroxaban – adults 15–20 mg PO every 24 hours; children by weight:

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