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Pain, distress ?
 Morphine IV 5 mg (2 mg in elderly, COPD)
Oxygen sat < 95% despite O ?
 Increase FiO2
 CPAP 5-7.5 cm H O, BiPAP if resp. acidosis
 Mechanical ventilation if refractory resp. insuff.
Treat underlying arrhythmias, etiologies- Determine clinical picture
 See guidelines STEMI-NSTEMI
AHF + ACS ?
 Consider IABP, transfer to PCI centre
DECOMPENSATED CHF
HYPERTENSIVE AHF
PULMONARY EDEMA
CARDIOGENIC SHOCK
RIGHT HEART FAILURE
Echo ± PAC
Echo ASAP
FLUID Challenge if possible
DIURETICS
 Excessive volume load
 Mechanical ventilation
INOTROPIC AGENT
VASODILATORS if SBP > 110 mmHg
With caution if SBP < 90 - 110 mmHg
 INOTROPIC AGENT
Refractory ?
 VASOPRESSOR
Good clinical
Hypotension ?
 Inhaled nitric oxide
response ?
 Nitric oxide-ventilation
Chronic obstructive pulmonary
Acute heart failure
Acute coronary syndrome
ST segment elevation myocardial
infarction
Echo ± PAC
Refractory ?
NSTEMI non ST segment elevation
myocardial infarction
Intra aortic balloon pump
Chronic heart failure
Systolic blood pressure
Pulmonary artery catheter
Start or continue + optimize oral R/
Continuous positive airway pressure
Angiotensine receptor blocker
Diuretic-ACE inhibitor (ARB)- ß-blocker-aldosterone antagonist
 Consider IABP, assist device
Angiotensine converting enzyme
Consider device therapy in selected cases
 VASOPRESSOR
 Consider IABP, assist device
As soon as possible
Pharmacological treatment ‘Acute Heart Failure’
Initial treatment
Chronic peroral therapy after initial stabilization
Diuretics
Diuretics in function of volume overload
Loopdiuretics: dosing according to severity fluid overload
- Low dose in case of flash pulmonary edema, hypertensive heart failure
- Higher dose or continuous infusion in case of important fluid overload ACE – inhibitors
Furosemide
Captopril
Capoten®**
start 6.25 mg tid, target dose 50-100 mg tid Enalapril
Renitec®**
start 2.5 mg bid, target dose 10-20 mg bid (max 100 mg first 6h, max 240 mg first 24h) Lisinopril
Zestril®**
Bumetanide
Burinex®
continuous infusion: eg 6 vials/50cc glucose, Ramipril
Tritace®**
Intolerance ACE inhibitors: ARB
In case of diuretic resistance:
Candesartan
Atacand®
Thiazides (Hydrochlorothiazide)
Valsartan
Diovane®
Management of
If contra-indication for ACE-I and ARB or persisting symptoms under ACE-I + ARB
Aldosterone
Spinorolactone
or ACE-I + aldosterone antagonist: consider hydralazinehydrochloride + nitrate ***
antagonist
- Aldactone®
Acute Heart Failure
ß-blocker
Bisoprolol
Emconcor®**
Vasodilators
Isoten®**
Isosorbide
Cedocard®
Carvedilol
Kredex®**
dinitrate
Metoprolosuccinate
Selozok®
Nebivolol
Nobiten®
Nitroglycerine
Nysconitrine®,
- Continuous infusion: start 10-20 μg/min, In selected cases add (see guidelines chronic heart failure)
Solinitra®*
Aldosterone antagonist
Nitroprusside
Nitriate®,
Digoxine
Nitropress®*
ACE-I + ARB
- Continuous infusion: start 0.3 μg/kg/min, Positive Inotropic agents
Cave adverse clinical outcome and increased mortality
Bèta-agonists
Dobutamine
2-20 μg/kg/min, initiate at 2-3 μg/kg/min Indication: Hypotension due to reduced contractility, right ventricular failure
Dopamine
Indication: Diuretic resistance, shock > 5 μg/kg/min: inotropic + vasopressive effect ( ) PDE- III inhibitors :
Indication: peripheral hypoperfusion with preserved systemic bloodpressure, Milrinone
Corotrope®
10 mg/10 ml vial followed by continuous infusion Enoximone
Perfan®
100 mg/20 ml vial followed by continuous infusion Calcium sensitizer:
Indication: need for inotropic support (not if SBP < 85 mmHg), can be combined with ß– blocker
Levosimendan
Symdax®*
12.5 mg/5 ml vial (not if SBP < 100 mmHg) Vasopressors
Only if fluid challenge and inotropic agents fail to restore adequate bloodpressure,
at the lowest dose and as short as possible
Norepinephrine
Indication: preferred vasopressor if vascoconstrictive effect is rapidly needed
Epinephrine

Source: http://biwac.be/site/wp-content/uploads/2011/05/AHF.pdf