Management Principles

The priorities in management include:

• Respiratory support
• Hemodynamic stabilization
• Congestion relief
• Restoration of adequate perfusion
• Limiting organ injury
• Monitoring for arrhythmias
• Planning hospital discharge and follow-up

Desired Outcomes

• Relief of congestive symptoms
• Restoration of adequate end-organ perfusion
• Optimization of volume status and hemodynamic stability
• Minimization of further cardiac damage and adverse drug reactions
• Appropriate initiation/titration of guideline-directed medical therapies

General Approach

• Discontinue medications worsening heart failure (e.g. NSAIDs, thiazolidinediones)
• Initiate intravenous loop diuretics for congestion, using 1-2.5 times oral dose
• Continue beta-blockers and other guideline-directed medical therapies if possible
• Select additional therapies based on hemodynamic profile

Pharmacologic Therapy

• Diuretics: Loop diuretics (e.g. furosemide, bumetanide) are first-line for volume overload. May need combination with thiazide diuretics for diuretic resistance.
• Vasodilators: Nitroglycerin, nitroprusside – Used for rapid symptom relief in hypertensive ADHF with pulmonary edema.
  •   Hemodynamic effects:  ↓ PCWP, ↓ SVR, ↓ MAP, ↑ CO
• Inotropes: Dobutamine, milrinone – Reserved for cardiogenic shock refractory to other measures. Increase contractility and cardiac output.
• Vasopressors: Norepinephrine, dopamine – Used in conjunction with inotropes for hypotensive shock with low blood pressure.
• Other agents: Morphine avoided due to risks. Vasopressin antagonists used for severe hyponatremia.

Non-pharmacologic Therapy

• Oxygenation/ventilation support
• Ultrafiltration for diuretic resistance
• Mechanical circulatory support devices in refractory shock
• Cardiac transplantation or left ventricular assist devices in advanced heart failure