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3.8: Therapy of acute heart failure

Last updated

Apr 12, 2024
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- 3.7: Pharmacological treatment
- 3.9: Management of HF beyond medication

de Jong and van der Waals Eds.
Cardionetworks Foundation and the Health[e]Foundation

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When severe symptoms of heart failure quickly develop over time, it is termed acute heart failure. In Table 3.8.1, common acute HF medications and their recommended doses are summarized. In Figure 3.8.1, a flowchart for the treatment of acute HF is depicted. The mainstay of acute heart failure therapy includes diuretics, vasodilators, inotropics and vasopressors. Moreover, oxygen and morphine can be added.

Table 3.8.1: Medication in acute heart failure
Medication	Condition	Dose
Diuretics	Adequate blood pressure and signs of overfilling
Furosemide i.v.	Renal failure	40 mg 125 mg – max 1000 mg
Bumetanide i.v.	Renal failure	1 mg 3 mg – max 25 mg
Vasodilators	Adequate blood pressure and signs of severe overfilling
Nitroglycerine i.v.		20 µg/min – max 200 µg/min (guided by blood pressure)
Nitroprusside i.v.	Hypertensive crisis or in combination with inotropic in case of a cardiogenic shock	0.3 µg/kg/min – max 5 µg/kg/min (guided by blood pressure)
Inotropes
Dobutamine i.v.	Low blood pressure and/or renal failure with or without overfilling	2-3 µg/kg/min – max 20 µg/kg/min
Dopamine i.v.	Low blood pressure and/or renal failure with or without overfilling	2-3 µg/kg/min – max 20 µg/kg/min
Enoximone i.v.	Signs of peripheral hypoperfusion with or without overfilling, and adequate blood pressure	0.25 – 0.75 mg/kg in 10 minutes; subsequently 1.25 – 7.5 µg/kg/min
Levosimendan i.v.	If beta-blockade is thought to be contributing to hypoperfusion	0.1 µg/kg/min, can be decreased to 0.05 or increased to 0.2 µg/kg/min
Vasopressors
Adrenalin i.v.	Restore circulation in cardiogenic shock
Noradrenalin i.v.	Septic shock

600px-Acute_hf_flowchart.svg.png — Figure 3.8.1: Flowchart for acute HF.

Patient presents at first aid or emergency room with signs of acute HF.

Table 7.3.2: Medication in chronic heart failure.
Medication	Condition	Dose
Loop Diuretic	Adequate blood pressure and signs of overfilling
Furosemide	Renal failure	40 mg 80 mg – max 1000 mg
Bumetanide	Renal failure	1 mg 2 mg – max 25 mg
ACE Inhibitors
Captopril		Start 6.25mg 1^st week 6.25mg three times daily. 3-5 weeks 12.5mg three times daily. >7 weeks 25mg three times daily.
Lisinopril		Start 2.5-5mg 1^st week 2.5-5mg twice daily. 3-5 weeks 5-10mg twice daily. >7 weeks 10-20mg twice daily.
Beta Blockers
Metoprolol zoc (succinate)	EF >30-45% and NYHA II-III	Start 25mg 1^st week 50mg once daily. 3-5 weeks 100mg once daily. >7 weeks 100-200mg once daily.
	EF <30% and NYHA IV	Start 12.5mg 1^st week 25mg once daily. 3-5 weeks 50mg once daily. >7 weeks 100-200mg once daily.
Bisoprolol	EF >30-45% and NYHA II-III	Start 2.5mg 1^st week 3.75mg once daily. 3-5 weeks 5mg once daily. >7 weeks 7.5-10mg once daily.
	EF <30% and NYHA IV	Start 1.25mg 1^st week 2.5mg once daily. 3-5 weeks 3.75mg once daily. >7 weeks 5-7.5-10mg once daily.
Carvedilol	EF >30-45% and NYHA II-III	Start 6.25mg 1^st week 6.25mg twice daily. 3-5 weeks 12.5mg twice daily. >7 weeks 25mg twice daily.
	EF <30% and NYHA IV	Start 3.125mg 1^st week 3.125mg twice daily. 3-5 weeks 6.25mg twice daily. >7 weeks 12.5-25mg twice daily.
Nebivolol	EF >30-45% and NYHA II-III	Start 1.25mg 1^st week 2.5mg once daily. 3-5 weeks 5mg once daily. >7 weeks 10mg once daily.
	EF <30% and NYHA IV	Start 1.25mg 1^st week 2.5mg once daily. 3-5 weeks 5mg once daily. >7 weeks 10mg once daily.
Aldosterone antagonist
Spironolactone/eplerenone		Start 25mg s.i.d. 1^st week potassium <5.0: 25mg once daily. potassium 5.0-5.5: 12.5mg once daily. potassium >5.5: stop 3rd week potassium <5.0: 25mg once daily. potassium 5.0-5.5: 12.5mg once daily. potassium >5.5: stop
Digoxin		Start 0.5mg, 0.25mg and 0,25 mg, each with 6 hours in between Continue with 0.25mg once daily. Half dose with age above 70 or creatinin above 110 or with amiodarone use
AT II blockers
Candesartan		Start 4mg 3-5 weeks 8mg once daily. >7 weeks 16mg once daily.
Valsartan		Start 40mg twice daily 3-5 weeks 80mg twice daily. >7 weeks 160mg twice daily.
Hydralazine and isosorbide dinitrate (H-ISDN)
Hydralazine		Start 25mg three times daily. 3-5 weeks 50mg three times daily. >7 weeks 75-100mg three times daily.
ISDN		Start 20mg twice daily 3-5 weeks 40mg twice daily >7 weeks 80mg twice daily

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