Table of Contents
Include in assessment
- ECG – the acute LVF may be caused by ACS or an arrhythmia
- Catheterise and implement strict fluid balance charting
- Serial weights
- B-type natriuretic peptide
- Troponin if ACS suspected
Initial ABCDE approach
Follow usual ABCDE approach if critically ill.
Treatment – POND
- Position (sit up)
- Oxygen (high-flow initially; titrate to keep oxygen saturations 92-96%, consider CPAP on CCU or HDU if required)
- Nitrates in severe pulmonary oedema (GTN infusion if SBP >110, or 2 puffs GTN spray if SBP 90-110)
- Diuretic if fluid overloaded or usually on it (e.g. furosemide 40mg IV initially)
- +treat cause
Identify and treat cause
- ACS → see notes on ACS
- Arrhythmia → see notes on arrhythmias
- Tamponade → pericardiocentesis
- Acute aortic/mitral regurgitation → valve replacement
- Hypertensive crisis → BP management
- Fluid overload → regular furosemide
Further interventions if required
- CPAP if hypoxaemic despite above interventions
- Inotropes ± intra-aortic balloon pump in ICU if in cardiogenic shock (hypotension + overload)
Long-term heart failure management
- Treat cause where possible
- Diuretic (e.g. furosemide, bumetanide) if fluid overloaded
- Treatments with prognostic benefit for heart failure with reduced ejection function (use all)
- ACE inhibitor or angiotensin receptor blocker or angiotensin receptor-neprilysin inhibitor (e.g. sacubitril/valsartan)
- β-blocker (e.g. bisoprolol)
- Aldosterone antagonist (e.g. spironolactone, eplerenone)
- SGLT2-inhibitor (e.g. dapagliflozin, empagliflozin)
- Control specific causes/associated conditions (e.g. hypertension, AF, obesity, diabetes, myocardial ischaemia) for heart failure with preserved ejection function
- Non-pharmacological treatments
- Cardiac resynchronisation therapy device: considered if QRS significantly prolonged
- Implantable cardioverter defibrillator: considered if risk of ventricular arrhythmias
Test your knowledge
What is the formula to determine cardiac output?
What is preload, contractility and afterload? How are they related to stroke volume? What happens to these in heart failure?
How do nitrates work in severe pulmonary oedema?
In a patient admitted with fluid overload receiving intravenous diuresis, what is your daily fluid balance and weight loss target?
Learn more here…
There’s more learning on heart failure here!