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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

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