Acute Heart Failure syndrome made simple

• Acute heart failure syndrome (AHFS) spectrum can be divided into 5 groups as regards therapeutic management: 
• (i) Dyspnoea + /- congestion with elevated systolic blood pressure (SBP)>140 mmHg, usually with abrupt onset (acute pulmonary oedema) APO (most frequent type)
• (ii) Dyspnoea + /- congestion with normal SBP 100-140 mmHg, usually with gradual onset predominant systemic oedema and milder APO
• (iii) Dyspnoea + /- congestion with low SBP <100 mmHg, with predominant cardiogenic shock or end-stage cardiac failure (most fatal type)
• (iv) Dyspnoea + /- congestion with signs of ACS such as chest pain
• (v) Isolated RV failure usually without APO.

• Treatment aims

  • Decrease left ventricular diastolic pressure, by decreasing systemic vascular resistance and improving systolic and diastolic functional reserve.
  • Promote coronary blood flow.
  • Correct acute respiratory failure.
  • In-hospital mortality for APO is up to 12%, with one-year mortality up to 40%.

• Drugs

• Nitroglycerin S/L, topical or IV titrated to avoid hypotension.
• Most rapidly venodilates, reduces LV afterload and corrects myocardial ischaemia. Ideal for AHFS type 1. (i) above.
• Also consider in AHFS types 1. (ii) and (iv) if SBP > 110 mmHg.
• Avoid in AHFS type 1. (iii) above.
• Nitrates are used less often than frusemide + were used in just 27% of the patients admitted in the ADHERE registry (USA, 2003)

• Frusemide IV.  Despite universal use, absolute efficacy is unclear. May cause decrease in cardiac output and increase PVR, plus increase PAOP in more chronic HF. Ideal for AHFS type 1. (ii) above.

• ACE inhibitor IV, orally or SC also reduces pre- and afterload, but little data in acute situation. Precipitous hypotension is hard to reverse, so use is best reserved for longer term management of HF.

• Morphine has relatively ineffective / unproven acute venodilating and sympatholytic effects, is rarely used (3% one study) and may result in respiratory depression in face of NIV and/or a poorer outcome. May have role in APO with diastolic dysfunction (ie. EF >40%) with elevated SBP.

• Traditional inotropic support is with dobutamine, dopamine, milrinone, enoximone or salbutamol for AHFS type 1. (iii) above, but may disastrously increase myocardial oxygen demand, especially in ACS with AHFS type 1. see (iv) above. Rarely need to add vasoconstrictor noradrenaline.