akut.si

7/27/2019 akut.si

1/76

Acute exacerbation of congestive heart failureHighlights

SummaryOverview

BasicsDefinition

Epidemiology AetiologyPathophysiologyClassification

PreventionPrimaryScreeningSecondary

DiagnosisHistory & examinationTestsDifferential

Step-by-stepCriteriaGuidelinesCase history

TreatmentDetailsStep-by-stepEmergingGuidelinesEvidence

Follow UpRecommendations

ComplicationsPrognosis

ResourcesReferencesImagesOnline resourcesPatient leafletsCredits

EmailPrintFeedbackShare

Add to PortfolioBookmark Add notes

History & exam

Key factors presence of risk factors (previous cardiovascular disease, age >70 years)

dyspnoea
http://bestpractice.bmj.com/best-practice/monograph/62/highlights.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/highlights/summary.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/highlights/overview.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/basics.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/basics/definition.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/basics/epidemiology.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/basics/aetiology.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/basics/pathophysiology.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/basics/classification.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/prevention.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/prevention/primary.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/prevention/screening.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/prevention/secondary.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/history-and-examination.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/tests.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/differential.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/step-by-step.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/criteria.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/guidelines.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/case-history.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/treatment.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/treatment/details.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/treatment/step-by-step.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/treatment/emerging.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/treatment/guidelines.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/treatment/evidence.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/follow-up.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/follow-up/recommendations.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/follow-up/complications.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/follow-up/prognosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/images.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/online-resources.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/patient-leaflets.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/credits.htmlhttp://bestpractice.bmj.com/best-practice/emailfriend/62/highlights/overview.htmlhttp://bestpractice.bmj.com/best-practice/feedback/62/highlights/overview.htmlhttp://bestpractice.bmj.com/best-practice/share/62/highlights/overview.htmlhttp://portfolio.bmj.com/portfolio/add-to-portfolio.html?u=%3C;url%3Ehttp://bestpractice.bmj.com/best-practice/mybp/mybpSave.html?category=bookmark&dataKey=Acute+exacerbation+of+congestive+heart+failure+-+Overview&dataValue=%2Fbest-practice%2Fmonograph%2F62.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/history-and-examination.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/highlights.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/highlights/summary.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/highlights/overview.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/basics.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/basics/definition.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/basics/epidemiology.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/basics/aetiology.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/basics/pathophysiology.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/basics/classification.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/prevention.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/prevention/primary.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/prevention/screening.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/prevention/secondary.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/history-and-examination.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/tests.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/differential.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/step-by-step.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/criteria.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/guidelines.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/case-history.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/treatment.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/treatment/details.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/treatment/step-by-step.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/treatment/emerging.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/treatment/guidelines.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/treatment/evidence.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/follow-up.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/follow-up/recommendations.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/follow-up/complications.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/follow-up/prognosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/images.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/online-resources.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/patient-leaflets.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/credits.htmlhttp://bestpractice.bmj.com/best-practice/emailfriend/62/highlights/overview.htmlhttp://bestpractice.bmj.com/best-practice/feedback/62/highlights/overview.htmlhttp://bestpractice.bmj.com/best-practice/share/62/highlights/overview.htmlhttp://portfolio.bmj.com/portfolio/add-to-portfolio.html?u=%3C;url%3Ehttp://bestpractice.bmj.com/best-practice/mybp/mybpSave.html?category=bookmark&dataKey=Acute+exacerbation+of+congestive+heart+failure+-+Overview&dataValue=%2Fbest-practice%2Fmonograph%2F62.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/history-and-examination.html

7/27/2019 akut.si

2/76

pulmonary crepitations

peripheral oedema

cool peripheries

chest pain

third heart sound (S3)

Other diagnostic factors fatigue and weakness

hypotension

tachycardia

elevated jugular venous pressure

displaced apex beat (point of maximal impulse)

dullness to percussion and decreased air entry in lung bases

wheezing

palpitations

cough

fever

syncope

murmur

ascites

hepatomegaly

central cyanosisHistory & exam details

Diagnostic tests

1st tests to order ECG

CXR

Hb

TFT

troponin

B-type natriuretic peptide (BNP)

Tests to consider echocardiography

cardiac catheterisation

endomyocardial biopsy
http://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/history-and-examination.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/tests.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/history-and-examination.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/tests.html

7/27/2019 akut.si

3/76

Diagnostic tests details

Treatment details

Acute

haemodynamically stable

oxygen therapy morphine

loop diuretics

vasodilators

supportive care

ventilation

inadequate response to loop diuretics

o non-loop diuretics

due to cardiac ischaemia

o aspirin revascularisation

due to valvular disease

o nitroprusside

due to acute right heart failure

o treatment of underlying cause

due to acute myocarditis

o supportive care or immunosuppressant therapy

inadequate response to combination diuretics

o ultrafiltration

hypotensive (systolic BP

7/27/2019 akut.si

4/76

oxygen therapy

IV beta-blockers and glyceryl trinitrate

nitroprusside

supportive care

ventilation

Ongoing

acute episode stabilised: LVEF 100 mmHg

ACE inhibitor or angiotensin-II receptor antagonist

beta-blocker

aldosterone receptor antagonist

vasodilators

diuretics

supportive care

acute episode stabilised: LVEF

7/27/2019 akut.si

5/76

Diuretics and oxygen are initial treatments for symptom relief. Cardiogenic shock may require pressor

support or mechanical ventilation. If acute myocardial infarction (MI) is present, early revascularisation is essential.

Other related conditions Chronic congestive heart failure

ST-elevation myocardial infarction

Non-ST-elevation myocardial infarction

Assessment of cardiomyopathy

Myocarditis

Aortic stenosis

Mitral regurgitation

Pulmonary embolism

Acute respiratory distress syndrome

COPD

Acute asthma exacerbation in adults

Hypertensive emergencies Email Print Feedback Share Add to Portfolio Bookmark Add notes

CXR of acute pulmonary oedema showing increased alveolar markings, fluid in the horizontal fissure,and blunting of the costophrenic angles

From the private collections of Syed W. Yusuf, MBBS, MRCPI, and Daniel Lenihan, MD
http://bestpractice.bmj.com/best-practice/monograph/61.htmlhttp://bestpractice.bmj.com/best-practice/monograph/150.htmlhttp://bestpractice.bmj.com/best-practice/monograph/151.htmlhttp://bestpractice.bmj.com/best-practice/monograph/371.htmlhttp://bestpractice.bmj.com/best-practice/monograph/244.htmlhttp://bestpractice.bmj.com/best-practice/monograph/325.htmlhttp://bestpractice.bmj.com/best-practice/monograph/322.htmlhttp://bestpractice.bmj.com/best-practice/monograph/116.htmlhttp://bestpractice.bmj.com/best-practice/monograph/374.htmlhttp://bestpractice.bmj.com/best-practice/monograph/7.htmlhttp://bestpractice.bmj.com/best-practice/monograph/45.htmlhttp://bestpractice.bmj.com/best-practice/monograph/27.htmlhttp://bestpractice.bmj.com/best-practice/emailfriend/62/resources/images/print/1-2-3-4-5.htmlhttp://bestpractice.bmj.com/best-practice/emailfriend/62/resources/images/print/1-2-3-4-5.htmlhttp://bestpractice.bmj.com/best-practice/feedback/62/resources/images/print/1-2-3-4-5.htmlhttp://bestpractice.bmj.com/best-practice/share/62/resources/images/print/1-2-3-4-5.htmlhttp://portfolio.bmj.com/portfolio/add-to-portfolio.html?u=%3C;url%3Ehttp://bestpractice.bmj.com/best-practice/mybp/mybpSave.html?category=bookmark&dataKey=Acute+exacerbation+of+congestive+heart+failure+-+resources.images.print&dataValue=%2Fbest-practice%2Fmonograph%2F62%2Fresources%2Fimages%2Fprint%2F1-2-3-4-5.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/1-2-3-4-5.htmlhttp://bestpractice.bmj.com/best-practice/monograph/61.htmlhttp://bestpractice.bmj.com/best-practice/monograph/150.htmlhttp://bestpractice.bmj.com/best-practice/monograph/151.htmlhttp://bestpractice.bmj.com/best-practice/monograph/371.htmlhttp://bestpractice.bmj.com/best-practice/monograph/244.htmlhttp://bestpractice.bmj.com/best-practice/monograph/325.htmlhttp://bestpractice.bmj.com/best-practice/monograph/322.htmlhttp://bestpractice.bmj.com/best-practice/monograph/116.htmlhttp://bestpractice.bmj.com/best-practice/monograph/374.htmlhttp://bestpractice.bmj.com/best-practice/monograph/7.htmlhttp://bestpractice.bmj.com/best-practice/monograph/45.htmlhttp://bestpractice.bmj.com/best-practice/monograph/27.htmlhttp://bestpractice.bmj.com/best-practice/emailfriend/62/resources/images/print/1-2-3-4-5.htmlhttp://bestpractice.bmj.com/best-practice/feedback/62/resources/images/print/1-2-3-4-5.htmlhttp://bestpractice.bmj.com/best-practice/share/62/resources/images/print/1-2-3-4-5.htmlhttp://portfolio.bmj.com/portfolio/add-to-portfolio.html?u=%3C;url%3Ehttp://bestpractice.bmj.com/best-practice/mybp/mybpSave.html?category=bookmark&dataKey=Acute+exacerbation+of+congestive+heart+failure+-+resources.images.print&dataValue=%2Fbest-practice%2Fmonograph%2F62%2Fresources%2Fimages%2Fprint%2F1-2-3-4-5.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/1-2-3-4-5.html

7/27/2019 akut.si

6/76

Left ventricular hypertrophy with sinus tachycardia


Systolic image of dilated left ventricle (arrow); note there is no change from diastolic image


7/27/2019 akut.si

7/76

Diastolic image of dilated left ventricle


CXR of acute pulmonary oedema showing increased alveolar markings and bilateral pleural effusions

7/27/2019 akut.si

8/76


Definition Acute congestive heart failure (CHF) is the rapid onset of symptoms andsigns due to abnormal cardiac function. It may be due to cardiac or extra-cardiac causes and results in reduced cardiac output, tissue hypoperfusion,increased pulmonary capillary wedge pressure, and tissue congestion. [1]

EpidemiologyBoth the incidence and prevalence of heart failure increase with age. [3] Inthe UK there were 60,480 cases of CHF in the 1-year period between 2006and 2007, with just more than 42,000 cases occurring in people over the ageof 75 years. [NHS. Hospital episode statistics] (external link) Studies of heartfailure in the US and Europe found that the annual incidence in people under 65 years of age is 1/1000 for men and 0.4/1000 for women. Over 65 years of age, the annual incidence is 11/1000 for men and 5/1000 for women. Under 65 years of age, the prevalence of heart failure is 1/1000 for men and 1/1000for women; over age 65 years the prevalence is 40/1000 for men and30/1000 for women. [3] Heart failure is the most common indication for hospitalisation in the US, andacute decompensated heart failure is the most common cause for hospitalisation among patients over 65 years. [4] The prevalence of heart failure in the US in 2004 was an estimated 5.2 millionpeople. It has significant public health implications and the estimated cost of heart failure in the US is $33.2 billion for the year 2007. The incidence of heart failure is around 10/1000 people over 65 years per year. [5] In the US,the mean age of people with heart failure is 74 years, with 52% being womenand mostly white people affected (73% to 78%). [6] [7] The average age of people with heart failure in studies conducted in Europe is also older than 70years, with slight predominance of men. [4] Heart failure is a global epidemic with a prevalence ranging from 11,000 to19,000 per million population among other countries. [8]

AetiologyCauses and precipitating factors in acute CHF are: [1]

Decompensation of pre-existing chronic heart failure

Acute coronary syndrome

Hypertensive crisis
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-3http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-3http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-3http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=203http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-3http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-3http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-3http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-4http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-4http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-4http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-5http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-5http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-5http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-4http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-4http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-4http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-8http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-8http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-8http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-3http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=203http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-3http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-4http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-5http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-4http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-8http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1

7/27/2019 akut.si

9/76

Acute arrhythmia

Valvular regurgitation

Severe aortic valve stenosis

Acute severe myocarditis

Cardiac tamponade

Aortic dissection

Post-partum cardiomyopathy

Non-cardiovascular precipitating factors

o Lack of compliance with medical treatment

o Volume overload

o Infections

o Severe brain insult

o After major surgery

o Reduction of renal function

o Asthma

o Drug abuse

o Phaeochromocytoma

High output syndromes

o Septicaemia

o Thyrotoxic crisis

o Anaemia

o Shunt syndromes.

7/27/2019 akut.si

10/76

The most common concurrent conditions present in patients with acute CHFare CAD, HTN, DM, atrial fibrillation, and renal insufficiency. [4] [9] Causes of right heart failure include: [10]

Secondary to LV failure

Secondary to pulmonary arterial hypertension

Secondary to right ventricle (RV) myopathic process

RV infarction

Arrythmogenic RV cardiomyopathy

Restrictive cardiomyopathy

Pericardial disease

Right-sided valvular disease

Congenital heart disease.

PathophysiologyDuring an episode of acute CHF, the majority of patients will have evidenceof volume overload with pulmonary and/or venous congestion.Haemodynamic measurements in these cases usually show increased right-and left-sided ventricular filling pressures with depressed cardiac index andcardiac output. However, if there is associated infection, the cardiac outputmay be normal or, in some cases, increased.

Activation of the sympathetic nervous system causes tachycardia, increasedmyocardial contractility, increased myocardial oxygen consumption,peripheral vasoconstriction, and activation of renin-angiotensin system withsalt and water retention. There is also activation of vasoconstrictor neurohormones, which leads to sodium and fluid retention, increasedmyocardial wall stress, and decreased renal perfusion. [11] If the condition is not treated effectively, the myocardium becomes unable tomaintain a cardiac output sufficient to meet the demands of the peripheralcirculation. In order for patients with acute CHF to respond quickly totreatment, the increased myocardial stress must be reversed; for example,correction of acute severe HTN. This is particularly important in acute CHF
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-4http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-4http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-4http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-10http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-10http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-10http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-11http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-11http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-11http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-4http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-10http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-11

7/27/2019 akut.si

11/76

caused by ischaemia, as a dysfunctional myocardium can return to normalwhen appropriately treated.

ClassificationClinical presentations [1]

Acute CHF has been classified by the European Society of Cardiology intofollowing clinical groups:

1. Acute decompensated heart failure (ADHF)

De novo or as decompensation of chronic CHF with signs and symptoms of ADHF, which are mild and

do not fulfil criteria for cardiogenic shock, pulmonary oedema, or hypertensive crisis.

2. Hypertensive acute CHF

Signs and symptoms of heart failure are accompanied by high blood pressure (BP) and relatively

preserved left ventricular (LV) function, with a CXR compatible with acute pulmonary oedema.

3. Pulmonary oedema (verified by CXR) View image View image Severe respiratory distress with associated crackles on lung examination, orthopnoea, and reduced

oxygen saturation, usually below 90% on room air before treatment.

4. Cardiogenic shock

Defined as evidence of tissue hypoperfusion induced by heart failure after correction of preload.

Usually characterised by reduced BP (systolic BP 30

mmHg) and/or low urine output (60 bpm, with or without evidence of organ

congestion.

There is a continuum from low cardiac output syndrome to cardiogenic shock.

5. High output failure

Characterised by high cardiac output, usually with high heart rate (caused by arrhythmias,thyrotoxicosis, anaemia, Paget's disease, iatrogenic, or other mechanisms), with warm peripheries, pulmonary

congestion, and, sometimes, with low BP such as in septic shock.

6. Right heart failure

Characterised by low output syndrome with increased jugular venous pressure, increased liver size, and

hypotension.
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/1.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/5.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/1.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/5.html

7/27/2019 akut.si

12/76

Clinical classification of acute heart failure (AHF) [2] For simplification these patients can be classified into 3 main groups:

1. Hypertensive AHF (acute de novo heart failure or vascular failure)

Symptoms develop rapidly against a background of hypertension (HTN) with increased sympathetic tone

and neurohormonal activations.

Left ventricular ejection fraction (LVEF) is usually preserved and there are clinical and radiological

findings of pulmonary congestion, usually without signs of systemic congestion; for example, peripheral oedema.

Response to therapy is rapid.

2. Normotensive AHF (acutely decompensated chronic heart failure)

History of progressive worsening of chronic heart failure.

BP is usually normal and symptoms and signs develop gradually with both systemic and pulmonary

congestion.

LVEF is usually reduced.

3. Hypotensive AHF

Presents with symptoms and signs of hypotension, organ hypoperfusion, and cardiogenic shock.

Types of heart failureSystolic

Associated with LV dysfunction and characterised by cardiomegaly, third heart sound, and volume

overload with pulmonary congestion. LVEF is decreased.

Diastolic

Typically associated with normal cardiac size, hypertension, pulmonary congestion, and a fourth heart

sound. LVEF is preserved.

Primary prevention Aggressive control and treatment of risk factors should be considered in order to prevent acute heart failure: CAD is managed with aspirin, beta-blockers,statins, and ACE inhibitors.
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-2http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-2http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-2http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-2

7/27/2019 akut.si

13/76

Optimising treatment of HTN, smoking cessation, and lipid control providessubstantial benefit in patients with CAD.

Optional control of HTN may require more than one antihypertensivemedication.

In asymptomatic patients with reduced LVEF, ACE inhibitors arecardioprotective and reduce further decline in LVEF. [19] Beta-blockers mayalso be considered in this group of patients.

All patients with diabetes mellitus (DM), in addition to metabolic control, needaggressive control of lipids, BP (target 70 years) (common)

Key risk factors include age over 70 years, previous cardiovascular disease, diabetes, and poor

compliance with medication for chronic CHF.dyspnoea (common) Predominant symptom and is present in the majority of patients with acute CHF. [9]

pulmonary crepitations (common)

Key finding on chest examination. [9] peripheral oedema (common)

Present in the majority of patients (around 65% of cases). [6] [9] cool peripheries (common)
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-19http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-19http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-19http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-20http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-20http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-21http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-21http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-22http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-22http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-22http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-35http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-35http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-35http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-36http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-36http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-36http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-19http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-20http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-21http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-22http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-35http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-36http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-9

7/27/2019 akut.si

14/76

is a key diagnostic factor chest pain (uncommon)

If underlying cardiac ischaemia.third heart sound (S3) (uncommon)

is a key diagnostic factor

Other diagnostic factorshide all

fatigue and weakness (common)

is a diagnostic factor hypotension (common)

is a diagnostic factor tachycardia (common)

Due to activation of the sympathetic nervous system or underlying arrhythmia.elevated jugular venous pressure (common)

is a diagnostic factor displaced apex beat (point of maximal impulse) (common)

is a diagnostic factor dullness to percussion and decreased air entry in lung bases (common)

Suggestive of pleural effusion.wheezing (common)

Suggests cardiac asthma.palpitations (uncommon)

If underlying arrhythmia.cough (uncommon)

Due to pulmonary congestion.fever (uncommon)

Suggestive of precipitating underlying infection.syncope (uncommon)

Suggestive of underlying cause, such as significant aortic stenosis or pulmonary embolism.murmur (uncommon)

Both significant stenotic and regurgitate lesions can lead to heart failure.ascites (uncommon)

is a diagnostic factor hepatomegaly (uncommon)

is a diagnostic factor central cyanosis (uncommon)

is a diagnostic factor Risk factors hide all

Strongage >70 years

A typical patient with acute heart failure is older than 70 years. [6] prior episode of congestive heart failure

In patients hospitalised for acute CHF, around 75% have a history of prior heart failure. [6]
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6

7/27/2019 akut.si

15/76

coronary artery disease

CAD accounts for around 50% of all patients with acute HF. [6] [7] [12] [13] Chronic myocardial

ischaemia results in myocardial damage with progressive decline in left ventricular (LV) systolic

function. Subendocardial ischaemia also causes increase in left ventricular end diastolic pressure

(LVEDP) leading to pulmonary oedema in the presence of normal LV systolic function. Acute coronary ischaemia can lead to acute CHF either due to pump failure or papillary muscle

destruction/rupture. In the case of pump failure, the LV function is depressed, but in cases of heart

failure associated with papillary muscle rupture, the measured LV function may appear preserved.hypertension

A history of HTN is present in 72% of patients in the US and 60% of patients from

Europe . [6] [12] [13] HTN predisposes to the development of heart failure by increasing the after-load on the ventricles,

which induces LVH, which in turn leads to LV dysfunction, an increased risk of MI, and significant

arrhythmias. In patients with non-compliant ventricles, an abrupt or significant increase in BP increases the

LVEDP, precipitating acute CHF.valvular heart disease

About 23% of patients in the US and 34% in Europe have valvular disease as an associated

condition. [6] [13] Both significant stenotic and regurgitate lesions can lead to heart failure. Although rheumatic valvular disease is now rarely found in western countries, calcific valvular heart

disease, in particular aortic stenosis, is commonly encountered. In patients with significant valvular disease, the heart failure will not improve until the underlying

valvular disease has been corrected.pericardial disease

A large pericardial effusion can present with symptoms or signs of acute CHF. Pericardial constriction, such as tuberculosis pericarditis or the effects of radiotherapy, can also

present with acute CHF.myocarditis

There are many causes of myocarditis, of which a viral aetiology appears to be the most common.

There is usually a prodrome of a non-specific illness characterised by fatigue, mild dyspnoea, and

myalgias.atrial fibrillation

Present in 31% of cases. [6] diabetes mellitus

Related directly to ischaemia and renal failure.non-compliance with medications

Precipitating factor in patients with chronic CHF.

Weak
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-13http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-13http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-13http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-13http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-13http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-13http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-13http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-13http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-13http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-6

7/27/2019 akut.si

16/76

excessive salt intake

Present in 22% of cases. [14] excessive catecholamine stimulation

Can be caused by phaeochromocytoma or subarachnoid haemorrhage. [15] abnormal thyroid function

Both hypothyroidism and thyrotoxicosis can be associated with heart failure. [16] [17] excessive alcohol intake

Excessive drinking is associated with heart failure (>3 drinks/day). [18]

Diagnostic tests1st tests to order hide allTest

ECG

The ECG analysis in acute CHF shows atrial fibrillation in 20% of cases and other abnormal rhythms in 26% of t

cases. [6]

ECG abnormality is found in almost all cases of heart failure. If the ECG is completely normal then alternate diashould be considered. [31] View image

CXR

Pulmonary congestion on CXR is present in up to 76% of patients with acute CHF. [6] View image View i

Hb

Suggests anaemia as a precipitating cause.

TFT

Hypo- or hyperthyroidism can cause acute CHF.

troponin

Elevated in acute cardiac ischaemia.

Also elevated in over 50% of cases of acute CHF without evidence of infarction. [25]

B-type natriuretic peptide (BNP)

If above 500 nanograms/L (>500 picograms/mL), dyspnoea likely to be due to CHF.

If below 100 nanograms/L (

7/27/2019 akut.si

17/76

echocardiography

Left ventricular ejection fraction (LVEF) 40% is transient systolic dysfunction or diagnostic dysfunction. [1]

Preserved LVEF (45%) is observed in 34% of patients with acute CHF. [13]

Guidelines from the European Association of Echocardiography state an LVEF of >55% is considered as normal

LVEF of 45% to 54% is mildly abnormal, LVEF of 30% to 44% is moderately abnormal, and an LVEF of 50% as normal.

cardiac catheterisation

Also detects haemodynamic derangements, valvular disease, and shunts.

endomyocardial biopsy

Only indicated if myocarditis is clinically suspected.

Differential diagnosisCondition

Differentiatingsigns/symptoms Differentiating tests

Pneumonia Fever, cough,

productive sputum.

Focal signs of

consolidation -

increased vocalfremitus and

bronchial

breathing.

WCC: elevated.

Blood cultures: positive for organism.

CXR: consolidation.

Pulmonary embolism Haemoptysis and

sharp, pleuritic

chest pain.

Risk factors of thromboembolism

(TE) include

personal history of TE, family history,

recent trauma,

prolonged

CT pulmonary angiography: clot in pulmonary artery
http://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/3.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/4.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-13http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-13http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-13http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-32http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-32http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-32http://bestpractice.bmj.com/best-practice/monograph/1113.htmlhttp://bestpractice.bmj.com/best-practice/monograph/116.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/3.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/4.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-13http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-32http://bestpractice.bmj.com/best-practice/monograph/1113.htmlhttp://bestpractice.bmj.com/best-practice/monograph/116.html

7/27/2019 akut.si

18/76

immobilisation,

smoker, or OCPuse.

Asthma

Wheezing onphysical

examination.

Reduced peak flow.

Spirometry: obstructive pattern, reversibility with be

Interstitial lung disease Progressively

increasingdyspnoea.

Oxygen

desaturation withexercise.

Fine bibasal

crepitations with

no other signs of

heart failure.

CXR: reticular infiltrate in the late stages of disease.

High-resolution CT scan: ground-glass appearance, r

honeycombing, and architectural distortion.

Spirometry: restrictive pattern.

Adult respiratory distresssyndrome

Severe hypoxia,

fine crepitations.

CXR: diffuse infiltrates

Pulmonary artery wedge pressure:

7/27/2019 akut.si

19/76

and pulmonary embolism, and precipitating factors causing exacerbation of chronic CHF such as dietary indiscretion with excessive salt intake, non-compliance with medications, and excessive alcohol or drug intake.

SymptomsHeart failure presents with dyspnoea, decreased exercise tolerance, swellingof the legs, fatigue, and generalised weakness. Sometimes the patient maypresent with predominant symptoms of the underlying condition, such aschest pain, syncope, palpitations, or viral prodrome.

SignsCommon signs include central cyanosis, tachycardia, elevated jugular venouspressure (JVP), displaced apex beat, S3, crepitations or pleural effusion,hepatomegaly, ascites, and oedema. The presence of these signs dependsupon the duration, acuity, and the underlying cause of heart failure. Patientswith end-stage heart failure may exhibit most of these clinical signs, whereasthose in the early phase of the illness may have minimal signs.

Patients with acute CHF can be classified clinically into 4 haemodynamicprofiles. [24] These profiles, which are based on haemodynamic principles of presence or absence of elevated filling pressure (wet or dry) and perfusionthat is adequate or critically limited (warm or cold), include:

Warm and dry

Warm and wet

Cold and dry

Cold and wet.

Patients with pulmonary oedema present with severe respiratory distress withreduced oxygen saturation (usually 60 bpm and/or low urine output (

7/27/2019 akut.si

20/76

An ECG and CXR should be performed immediately in all patients withsuspected acute CHF. ECG findings are commonly related to the underlyingpathologies and include presence of Q waves, ST-T changes, left ventricular hypertrophy (LVH), left bundle branch block, and atrial fibrillation. View imageCXR may show cardiac enlargement (cardiothoracic ratio >50%); however,

there is poor correlation between the cardiothoracic ratio (CTR) and presenceof heart failure, as the heart size may be normal in patients with diastolicdysfunction, acute valvular regurgitation as part of infective endocarditis, or acute MI. An enlarged CTR may also be seen in the absence of heart failure(e.g., pericardial effusion and LVH).

Evaluation of the lung fields will show signs of pulmonary congestion, initiallyin the upper zones, then in the horizontal fissures followed by pulmonaryoedema and pleural effusion. View image View image The x-ray findings have

to be taken in the context of clinical picture, as pulmonary infiltrates andcongestion, in some cases, may be due to non-cardiac cause such as ARDSor alveolar haemorrhage.CXRs rarely may show pericardial calcification, prosthetic valves, or valvular calcification. In these situations, it is helpful in identifying the possibleunderlying aetiology for heart failure.

The following blood tests should be requested when patients present withsuspected acute CHF: [22]

Hb: may identify anaemia as a contributing factor.

TFTs: both hypothyroidism and hyperthyroidism can cause heart failure.

Cardiac enzymes: >50% of patients with cardiogenic pulmonary oedema (but without evidence for MI)

have elevated troponin T levels. [25] Elevated troponin T levels in patients with acute CHF may reflect

subendocardial ischaemia due to elevated left ventricular end diastolic pressure. In patients with acute

cardiogenic pulmonary oedema, a troponin T level of 0.1 g/L (0.1 ng/mL) is a powerful independent predictor

and is associated with poor long-term survival. [25] BNP: measurement of serum BNP level in patients with symptoms of heart failure is now routinely

carried out in most centres. The addition of BNP or N-terminal pro-brain natriuretic peptide (NT-proBNP) levelsto clinical assessment significantly enhances the accuracy of diagnosis and effectiveness of acute

management. [26] [27] BNP is also helpful in differentiating a cardiac from a pulmonary cause of

dyspnoea. [28] An elevated BNP level is a predictor of in-hospital mortality in patients with acute decompensated

heart failure. [29] However, an elevated BNP level should only be taken in the context of clinical picture as it may

be increased in a variety of other condition, such as atrial fibrillation, pulmonary embolism, or sepsis. [30]
http://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/2.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/1.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/5.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-22http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-22http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-22http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-25http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-25http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-25http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-25http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-25http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-25http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-26http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-26http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-26http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-27http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-27http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-28http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-28http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-28http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-29http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-29http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-29http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-30http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-30http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-30http://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/2.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/1.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/5.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-22http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-25http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-25http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-26http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-27http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-28http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-29http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-30

7/27/2019 akut.si

21/76

Subsequent investigationsEchocardiogram is an integral part of the evaluation in a patient with acuteCHF and should be performed as soon as possible to presentation. It isrequired to assess chamber size, ventricular function (systolic and diastolic),ventricular wall thickness, valvular function, and the pericardium. Viewimage View imageCardiac catheterisation is needed in cases where significant CAD is thoughtto be the contributing factor, and is also indicated in cases where the causeof acute CHF can not be determined from other tests.

Endomyocardial biopsy is not recommended for routine evaluation of acuteCHF, but is indicated in patients whose clinical findings suggest acutemyocarditis.

Click to view diagnostic guideline references. Diagnostic criteriaFramingham criteria for CHF [33] The Framingham criteria are the most widely accepted clinical criteria for diagnosing heart failure. For establishing a definite diagnosis of CHF, 2 major criteria or 1 major and 2 minor criteria must be present.

Major criteria are:

Paroxysmal nocturnal dyspnoea or orthopnoea

Neck-vein distention

Rales

Cardiomegaly

Acute pulmonary oedema

S3 gallop

Increased venous pressure >16 cm of water

Circulation time 25 seconds or longer

Hepatojugular reflux.

Minor criteria are:
http://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/3.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/3.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/4.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/guidelines.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-33http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-33http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-33http://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/3.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/3.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/images/print/4.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/diagnosis/guidelines.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-33

7/27/2019 akut.si

22/76

Ankle oedema

Night cough

Dyspnoea on exertion

Hepatomegaly

Pleural effusion

Vital capacity reduced one third from maximum

Tachycardia (120 bpm).

Major or minor criteria are:

Weight loss of 4.5 kg or more in 5 days in response to treatment.

New York Heart Association (NYHA) clinical classificationof heart failure [34]

Class I: asymptomatic

Class II: mild symptoms with moderate exertion

Class III: symptoms with minimal activity

Class IV: symptoms at rest.

Case history #1 A 70-year-old woman complains of increasing exertional dyspnoea for thelast 2 days and now has dyspnoea at rest. She has a history of hypertensionfor the last 5 years and a 35 pack-year smoking history, but no other established illnesses. Current medications are hydrochlorothiazide daily for the last 3 years. She has been prescribed lisinopril but failed to fill the

prescription. On examination her BP is 190/90 mmHg, heart rate 104 bpm.There is an audible S4 and the jugular venous pressure (JVP) is elevated 2cm above normal. Lung examination reveals fine bibasal crepitations. Thereis no ankle oedema.
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-34http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-34

7/27/2019 akut.si

23/76

Case history #2 A 73-year-old woman presents to the emergency department havingcollapsed. She is breathless and finding it difficult to talk in full sentences. Onexamination she is centrally cyanosed with cool extremities. Her pulse is 110

bpm and systolic BP only just recordable at 80 mmHg. Jugular venouspressure (JVP) is elevated 3 cm above normal and the cardiac apex beat isdisplaced. Respiratory rate is increased and she has widespread cracklesand wheezes on chest examination.

Other presentationsPatients may present with predominant symptoms of the underlying conditionsuch as chest pain with acute MI, syncope with significant valvular stenosis,palpitations with arrhythmias, and viral prodrome with myocarditis.

Treatment Options

Patient group

Treatment

line Treatment hide all

haemodynamically stable 1st oxygen therapy Oxygen saturation should ideally be maintained

between 95% and 98% to maximise tissue

oxygenation.

adjunct

[?]morphine

Morphine results in mild vasodilatation and slows

the heart rate. It is particularly useful if the patient is

restless and significantly dyspnoeic. [1]

Primary Options

morphine sulphate : 2.5 to 10 mg intravenously

every 2-6 hours when required

plus

[?]loop diuretics

Indicated in patients with a systolic BP >85

mmHg. [1]

Primary Options

furosemide : 40-160 mg/dose orally/intravenously

initially, increase by 20-40 mg/dose every 6-12
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-68&optionId=expsec-637860&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-69&optionId=expsec-637863&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-69&optionId=expsec-637863&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-68&optionId=expsec-637860&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-69&optionId=expsec-637863&dd=MARTINDALE

7/27/2019 akut.si

24/76

Patient group

Treatment




oxygenation.

hours according to response, maximum 600

mg/day

OR

bumetanide : 0.5 to 2 mg orally/intravenously once

or twice daily initially, increase dose according to

response, maximum 10 mg/day

OR

torasemide : 5-20 mg orally once daily initially,increase dose according to response, maximum 40

mg/day

plus

[?]vasodilators

Indicated in patients with pulmonary

congestion/oedema and a systolic BP >90

mmHg. [39] [56] Both IV nitroglycerin and nesiritide lower left

ventricular filling pressure and provide symptomatic

improvement. [57] Nitroglycerin is the preferred agent with nesiritide

considered less preferred, as there is some

concern about worsening in renal function with

nesiritide and increased mortality. [40] [58] [59] However, a recent retrospective observational

analysis from the ADHERE study showed that both

nesiritide and nitroglycerin are equally safe in thetreatment of acute CHF. [12]

Primary Options

glyceryl trinitrate : 5 micrograms/min intravenously

initially, increase by 5-20 micrograms/min

increments every 3-5 minutes according to
http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-70&optionId=expsec-637863&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-70&optionId=expsec-637863&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-71&optionId=expsec-637863&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-71&optionId=expsec-637863&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-39http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-39http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-39http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-56http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-56http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-57http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-57http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-57http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-40http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-40http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-40http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-58http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-58http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-59http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-59http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-72&optionId=expsec-637866&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-70&optionId=expsec-637863&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-71&optionId=expsec-637863&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-39http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-56http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-57http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-40http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-58http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-59http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-72&optionId=expsec-637866&dd=MARTINDALE

7/27/2019 akut.si

25/76

Patient group

Treatment




oxygenation.

response, maximum 200 micrograms/min

Secondary Options

nesiritide : 2 micrograms/kg/dose intravenous bolusinitially, followed by 0.01 micrograms/kg/min

infusion

plus

[?]supportive care

Continued supportive care includes maintenance of

adequate oxygenation (ideally maintained between

95% and 98% to maximise tissue oxygenation),

patent airways, a low salt diet, and restriction of

daily fluid intake.

adjunct

[?]ventilation

Required if oxygen saturation cannot be maintained

with oxygenation alone. [1] Non-invasive positive pressure ventilation (NIPPV)

or CPAP should be tried first. Mechanical

ventilation is only used when other treatmentsincluding NIPPV fail.

inadequate response to loop

diuretics

adjunct

[?]non-loop diuretics

Indicated in patients with a systolic BP >85

mmHg. [1] Non-loop diuretics are commonly used in

combination with loop diuretics to improve diuresis.

Primary Options

spironolactone : 25-100 mg orally once daily

OR

eplerenone : 25-50 mg orally once daily

OR
http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-73&optionId=expsec-637866&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-73&optionId=expsec-637866&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-37&optionId=expsec-637890&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-38&optionId=expsec-637890&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-73&optionId=expsec-637866&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-37&optionId=expsec-637890&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-38&optionId=expsec-637890&dd=MARTINDALE

7/27/2019 akut.si

26/76

Patient group

Treatment




oxygenation.

metolazone : 2.5 to 10 mg orally once daily

due to cardiac ischaemia plus

[?]aspirin revascularisation

Aspirin is given to all patients (in the absence of

contra-indication) with coronary ischaemia and

those undergoing revascularisation. Revascularisation may be achieved with

percutaneous revasculatisation or, in selected

cases, with coronary artery bypass grafting.

Primary Options

aspirin : 300 mg orally as a single dose, followed by

75 mg once daily thereafter

due to valvular disease adjunct

[?]

nitroprusside

Indicated in patients with aortic stenosis, aorticregurgitation, mitral stenosis, or mitral regurgitation

who are not hypotensive. Dose of nitroprusside exceeding 400

micrograms/minute generally does not produce

added benefit and may increase the risk of

thiocyanate toxicity. [55]

Primary Options

nitroprusside : 0.3 micrograms/kg/min intravenouslyinitially, increase by 0.5 micrograms/kg/min

increments according to response, usual dose is 5

micrograms/kg/min

due to acute right heart failure plus

[?]treatment of underlying cause

Therapy is centred around treatment of the

underlying pathology; e.g., pulmonary embolism
http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-39&optionId=expsec-637890&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-40&optionId=expsec-637887&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-40&optionId=expsec-637887&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-41&optionId=expsec-637884&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-39&optionId=expsec-637890&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-40&optionId=expsec-637887&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-41&optionId=expsec-637884&dd=MARTINDALE

7/27/2019 akut.si

27/76

Patient group

Treatment




oxygenation.

(anticoagulation, thrombolytics, catheterisation, or

surgically directed thrombectomy), right ventricular

infarction (PCI or thrombolytics), and chronic

thromboembolic pulmonary hypertension

(thromboendarterectomy). [49]

due to acute myocarditis plus

[?]supportive care or immunosuppressant therapy

Giant cell myocarditis is treated with single or

combination immunosuppressant therapy including

corticosteroids, azathioprine, cyclosporine, andmuromonab-CD3 (OKT3). [50]

Treatment of other forms of myocarditis is limited to

supportive care. [51]

inadequate response to

combination diuretics

adjunct

[?]ultrafiltration

For patients with volume overload who do not

respond to medical therapy.


7/27/2019 akut.si

28/76

Patient group

Treatment




oxygenation.

Evidence] [B Evidence] The infusion rate is modified according to

symptoms, diuretic response, or haemodynamicmonitoring.

Choice of inotrope depends on clinical findings. Dobutamine or milrinone are recommended for

patients with systolic BP 85 to 100 mmHg and noclear clinical evidence of shock (such as cold

extremities and low urine output). [1] Levosimendan, a calcium sensitiser, is a new drug

that is sometimes recommended as an alternative

to dobutamine or milrinone; however, it is not

commonly used in practice, and may not be

available in some countries (including the

US) . [44] [45] [46] [47] Avoid if the patient is very


7/27/2019 akut.si

29/76

Patient group

Treatment




oxygenation.

dobutamine : 2-20 micrograms/kg/min

intravenously

OR

dopamine : 5-15 micrograms/kg/min intravenously

OR

norepinephrine : 0.5 to 30 micrograms/minintravenously

plus

[?]supportive care



95% and 98% to maximise tissue oxygenation),

patent airways, a low salt diet, and restriction of

daily fluid intake.

adjunct

[?]ventilation




ventilation is only used when other treatments

including NIPPV fail.

2nd intra-aortic balloon pump Required in patients with persistent cardiogenic

shock, despite inotropic therapy.3rd left ventricular assist device (LVAD)

The use of LVADs has evolved significantly over

the past 25 years and various types of LVAD now

exist. Extracorporeal devices, the most common of

which are the extracorporeal membrane

oxygenators (ECMOs), require full heparinisation
http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-75&optionId=expsec-637896&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-75&optionId=expsec-637896&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-76&optionId=expsec-637896&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-77&optionId=expsec-637896&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-75&optionId=expsec-637896&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-76&optionId=expsec-637896&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-77&optionId=expsec-637896&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1

7/27/2019 akut.si

30/76

Patient group

Treatment




oxygenation.

and are typically used for days or weeks as a

bridge for patients who are expected to recover

within days. Percutaneous short-term devices (e.g.,

Tandem Heart) are inserted through the femoral

artery and advanced into the left ventricle. Longer-term assist devices are divided into first generation

(e.g., Heart Mate I), second generation (e.g., HeartMate II), and third generation (e.g., HVAD and Dura

Heart) devices. The third generation pumps are

thought to last as long as 5 to 10 years and arecurrently being evaluated in several phase 1

studies . [53]

due to cardiac ischaemia plus

[?]aspirin revascularisation

Aspirin is given to all patients (in the absence of

contra-indication) with coronary ischemia and those

undergoing revascularisation. Revascularisation may be achieved with

percutaneous revasculatisation or, as second-line

therapy, coronary artery bypass.

Primary Options

aspirin : 300 mg orally as a single dose, followed by

75 mg once daily thereafter

due to valve stenosis adjunct[?]

percutaneous valvotomy Used as a bridge to aortic valve replacement. May

be considered for mitral stenosis if no thrombuspresent on trans-oesophageal echocardiogram.

hypertensive crisis 1st oxygen therapy Oxygen saturation should ideally be maintained
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-42&optionId=expsec-637926&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-42&optionId=expsec-637926&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-42&optionId=expsec-637926&dd=MARTINDALE

7/27/2019 akut.si

31/76

Patient group

Treatment




oxygenation.

between 95% and 98% to maximise tissueoxygenation.

plus

[?]IV beta-blockers and glyceryl trinitrate

Primary Options

metoprolol : 5-10 mg intravenously every 4-6 hoursor

esmolol : 250-500 micrograms/kg/dose

intravenously over 1 minute initially, followed by 50-

100 micrograms/kg/min infusion for 4 minutes, may

repeat loading dose and increase infusion up to200 micrograms/kg/min according to response,

consult specialist for further guidance on dose

-- AND --

glyceryl trinitrate : 5 micrograms/min intravenously

initially, increase by 5-20 micrograms/minincrements every 3-5 minutes according to

response, maximum 200 micrograms/min

adjunct

[?]nitroprusside

Dose of nitroprusside exceeding 400

micrograms/minute generally does not produce

added benefit and may increase the risk of

thiocyanate toxicity. [55]

Primary Options

nitroprusside : 0.3 micrograms/kg/min intravenously

initially, increase by 0.5 micrograms/kg/min

increments according to response, usual dose is 5

micrograms/kg/min
http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-14&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-14&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-15&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-16&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-1&optionId=expsec-16&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-14&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-15&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-16&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-1&optionId=expsec-16&dd=MARTINDALE

7/27/2019 akut.si

32/76

Patient group

Treatment




oxygenation.

plus

[?]supportive care



95% and 98% to maximse tissue oxygenation),

patent airways, a low salt diet, and restriction of daily fluid intake.

Precipitating factors such as pain and agitationshould be also be controlled.

adjunct

[?]ventilation




ventilation is only used when other treatmentsincluding NIPPV fail.

Acute
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1

7/27/2019 akut.si

33/76

Patient group

Treatment


acute episode stabilised:

LVEF 100 mmHg

1st ACE inhibitor or angiotensin-II receptor antagonist An ACE inhibitor is the preferred agent. An

angiotensin-II receptor antagonist is only used in

patients who are intolerant of ACE inhibitors. A

combination of an ACE inhibitor and angiotensin-II

receptor blocker should be avoided because of therisk of renal dysfunction and hyperkalaemia.

Dose should be started low and increased according

to response. Treatment is targeted to maximum dosetolerated.

Primary Options

captopril : 6.25 to 50 mg orally three times daily

OR

lisinopril : 2.5 to 40 mg orally once daily

OR

ramipril : 1.25 to 10 mg orally once daily

OR

enalapril : 2.5 to 20 mg orally twice daily

Secondary Options

candesartan : 4-32 mg orally once daily

OR

losartan : 25-150 mg orally once daily

OR

valsartan : 40-160 mg orally twice daily

plus

[?]

beta-blocker

The pivotal trials with beta-blockers were conductedin patients with continuing symptoms and a

persistently low EF, despite treatment with an ACE

inhibitor and, in most cases, a diuretic. Despite this,there is consensus that these treatments are

complementary and that a beta-blocker and an ACE

inhibitor should both be started as soon as possible

after diagnosis of heart failure with reduced ejection

7/27/2019 akut.si

34/76

Patient group

Treatment



LVEF 100 mmHg








Primary Options


OR


OR


OR


Secondary Options


OR


OR


fraction (HF-REF). [37] Typically, beta-blockers are started only after the

patient has been stabilised and is in compensated

heart failure. Treatment is targeted to maximum dose tolerated.

Primary Options

bisoprolol : 1.25 mg orally once daily initially, increase
http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-61&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-61&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-62&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-63&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-64&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-64&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-65&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-65&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-66&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-67&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-67&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-37http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-37http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-37http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-86&optionId=expsec-682508&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-61&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-62&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-63&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-64&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-65&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-66&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-67&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-37http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-86&optionId=expsec-682508&dd=MARTINDALE

7/27/2019 akut.si

35/76

Patient group

Treatment



LVEF 100 mmHg








Primary Options


OR


OR


OR


Secondary Options


OR


OR


according to response, maximum 10 mg/day

OR carvedilol : 3.125 mg orally (immediate-release) twice

daily initially, increase according to response,

maximum 50 mg/day

OR

metoprolol : 12.5 to 200 mg orally (extended-release)

once daily
http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-87&optionId=expsec-682508&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-88&optionId=expsec-682508&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-87&optionId=expsec-682508&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-88&optionId=expsec-682508&dd=MARTINDALE

7/27/2019 akut.si

36/76

Patient group

Treatment



LVEF 100 mmHg







to response. Treatment is targeted to maximum dose

Date post:	02-Apr-2018
Category:	Documents
Upload:	micija-cucu
View:	216 times
Download:	0 times

akut.si

Documents