3.8: Therapy of acute heart failure
- Page ID
- 42740
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\(\newcommand{\avec}{\mathbf a}\) \(\newcommand{\bvec}{\mathbf b}\) \(\newcommand{\cvec}{\mathbf c}\) \(\newcommand{\dvec}{\mathbf d}\) \(\newcommand{\dtil}{\widetilde{\mathbf d}}\) \(\newcommand{\evec}{\mathbf e}\) \(\newcommand{\fvec}{\mathbf f}\) \(\newcommand{\nvec}{\mathbf n}\) \(\newcommand{\pvec}{\mathbf p}\) \(\newcommand{\qvec}{\mathbf q}\) \(\newcommand{\svec}{\mathbf s}\) \(\newcommand{\tvec}{\mathbf t}\) \(\newcommand{\uvec}{\mathbf u}\) \(\newcommand{\vvec}{\mathbf v}\) \(\newcommand{\wvec}{\mathbf w}\) \(\newcommand{\xvec}{\mathbf x}\) \(\newcommand{\yvec}{\mathbf y}\) \(\newcommand{\zvec}{\mathbf z}\) \(\newcommand{\rvec}{\mathbf r}\) \(\newcommand{\mvec}{\mathbf m}\) \(\newcommand{\zerovec}{\mathbf 0}\) \(\newcommand{\onevec}{\mathbf 1}\) \(\newcommand{\real}{\mathbb R}\) \(\newcommand{\twovec}[2]{\left[\begin{array}{r}#1 \\ #2 \end{array}\right]}\) \(\newcommand{\ctwovec}[2]{\left[\begin{array}{c}#1 \\ #2 \end{array}\right]}\) \(\newcommand{\threevec}[3]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \end{array}\right]}\) \(\newcommand{\cthreevec}[3]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \end{array}\right]}\) \(\newcommand{\fourvec}[4]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \\ #4 \end{array}\right]}\) \(\newcommand{\cfourvec}[4]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \\ #4 \end{array}\right]}\) \(\newcommand{\fivevec}[5]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \\ #4 \\ #5 \\ \end{array}\right]}\) \(\newcommand{\cfivevec}[5]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \\ #4 \\ #5 \\ \end{array}\right]}\) \(\newcommand{\mattwo}[4]{\left[\begin{array}{rr}#1 \amp #2 \\ #3 \amp #4 \\ \end{array}\right]}\) \(\newcommand{\laspan}[1]{\text{Span}\{#1\}}\) \(\newcommand{\bcal}{\cal B}\) \(\newcommand{\ccal}{\cal C}\) \(\newcommand{\scal}{\cal S}\) \(\newcommand{\wcal}{\cal W}\) \(\newcommand{\ecal}{\cal E}\) \(\newcommand{\coords}[2]{\left\{#1\right\}_{#2}}\) \(\newcommand{\gray}[1]{\color{gray}{#1}}\) \(\newcommand{\lgray}[1]{\color{lightgray}{#1}}\) \(\newcommand{\rank}{\operatorname{rank}}\) \(\newcommand{\row}{\text{Row}}\) \(\newcommand{\col}{\text{Col}}\) \(\renewcommand{\row}{\text{Row}}\) \(\newcommand{\nul}{\text{Nul}}\) \(\newcommand{\var}{\text{Var}}\) \(\newcommand{\corr}{\text{corr}}\) \(\newcommand{\len}[1]{\left|#1\right|}\) \(\newcommand{\bbar}{\overline{\bvec}}\) \(\newcommand{\bhat}{\widehat{\bvec}}\) \(\newcommand{\bperp}{\bvec^\perp}\) \(\newcommand{\xhat}{\widehat{\xvec}}\) \(\newcommand{\vhat}{\widehat{\vvec}}\) \(\newcommand{\uhat}{\widehat{\uvec}}\) \(\newcommand{\what}{\widehat{\wvec}}\) \(\newcommand{\Sighat}{\widehat{\Sigma}}\) \(\newcommand{\lt}{<}\) \(\newcommand{\gt}{>}\) \(\newcommand{\amp}{&}\) \(\definecolor{fillinmathshade}{gray}{0.9}\)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.
| Medication | Condition | Dose |
|---|---|---|
| Diuretics | Adequate blood pressure and signs of overfilling | |
|
Renal failure | 40 mg
125 mg – max 1000 mg |
|
Renal failure | 1 mg
3 mg – max 25 mg |
| Vasodilators | Adequate blood pressure and signs of severe overfilling | |
|
20 µg/min – max 200 µg/min (guided by blood pressure) | |
|
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 | ||
|
Low blood pressure and/or renal failure with or without overfilling | 2-3 µg/kg/min – max 20 µg/kg/min |
|
Low blood pressure and/or renal failure with or without overfilling | 2-3 µg/kg/min – max 20 µg/kg/min |
|
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 |
|
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 | ||
|
Restore circulation in cardiogenic shock | |
|
Septic shock | |
Patient presents at first aid or emergency room with signs of acute HF.
| Medication | Condition | Dose |
|---|---|---|
| Loop Diuretic | Adequate blood pressure and signs of overfilling | |
|
Renal failure | 40 mg
80 mg – max 1000 mg |
|
Renal failure | 1 mg
2 mg – max 25 mg |
| ACE Inhibitors | ||
|
Start 6.25mg
1st week 6.25mg three times daily. 3-5 weeks 12.5mg three times daily. >7 weeks 25mg three times daily. |
|
|
Start 2.5-5mg
1st week 2.5-5mg twice daily. 3-5 weeks 5-10mg twice daily. >7 weeks 10-20mg twice daily. |
|
| Beta Blockers | ||
|
EF >30-45% and NYHA II-III | Start 25mg
1st week 50mg once daily. 3-5 weeks 100mg once daily. >7 weeks 100-200mg once daily. |
| EF <30% and NYHA IV | Start 12.5mg
1st week 25mg once daily. 3-5 weeks 50mg once daily. >7 weeks 100-200mg once daily. |
|
|
EF >30-45% and NYHA II-III | Start 2.5mg
1st 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
1st week 2.5mg once daily. 3-5 weeks 3.75mg once daily. >7 weeks 5-7.5-10mg once daily. |
|
|
EF >30-45% and NYHA II-III | Start 6.25mg
1st 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
1st week 3.125mg twice daily. 3-5 weeks 6.25mg twice daily. >7 weeks 12.5-25mg twice daily. |
|
|
EF >30-45% and NYHA II-III | Start 1.25mg
1st week 2.5mg once daily. 3-5 weeks 5mg once daily. >7 weeks 10mg once daily. |
| EF <30% and NYHA IV | Start 1.25mg
1st week 2.5mg once daily. 3-5 weeks 5mg once daily. >7 weeks 10mg once daily. |
|
| Aldosterone antagonist | ||
|
Start 25mg s.i.d.
1st 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 |
|
|
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 | ||
|
Start 4mg
3-5 weeks 8mg once daily. >7 weeks 16mg once daily. |
|
|
Start 40mg twice daily
3-5 weeks 80mg twice daily. >7 weeks 160mg twice daily. |
|
| Hydralazine and isosorbide dinitrate (H-ISDN) | ||
|
Start 25mg three times daily.
3-5 weeks 50mg three times daily. >7 weeks 75-100mg three times daily. |
|
|
Start 20mg twice daily
3-5 weeks 40mg twice daily >7 weeks 80mg twice daily |
|