From the Guidelines
Management of acute cardiac insufficiency should prioritize the use of intravenous loop diuretics, such as furosemide, to reduce fluid overload and improve symptoms, as recommended by the 2016 ESC guidelines 1. The initial dose of furosemide should be 20-40 mg IV for patients not receiving oral diuretics, and at least equivalent to the oral dose for those on chronic diuretic therapy 1. Key considerations in the management of acute cardiac insufficiency include:
- Monitoring symptoms, urine output, renal function, and electrolytes during diuretic use 1
- Adjusting the dose and duration of diuretics according to the patient's symptoms and clinical status 1
- Considering the use of vasodilators, such as i.v. vasodilators, for symptomatic relief in patients with systolic blood pressure >90 mmHg 1
- Using inotropic agents, such as dobutamine or levosimendan, in patients with hypotension and/or signs of peripheral hypoperfusion, but with caution due to safety concerns 1
- Implementing thrombo-embolism prophylaxis, such as low molecular weight heparin, to reduce the risk of deep venous thrombosis and pulmonary embolism 1 The goal of these interventions is to improve cardiac output, reduce congestion, and optimize tissue perfusion, while also addressing the underlying cause of cardiac insufficiency. In patients with hypertensive acute heart failure, i.v. vasodilators should be considered as initial therapy to improve symptoms and reduce congestion 1. Additionally, it is essential to monitor ECG and blood pressure when using inotropic agents and vasopressors, as they can cause arrhythmia, myocardial ischemia, and hypotension 1. Overall, the management of acute cardiac insufficiency requires a multifaceted approach that prioritizes the use of evidence-based therapies to improve symptoms, reduce morbidity, and mortality, and enhance quality of life.
From the FDA Drug Label
In two placebo controlled, 12-week clinical studies compared the addition of lisinopril up to 20 mg daily to digitalis and diuretics alone. The combination of lisinopril, digitalis and diuretics reduced the following signs and symptoms of heart failure: edema, rales, paroxysmal nocturnal dyspnea and jugular venous distention A large (over 3,000 patients) survival study, the ATLAS Trial, comparing 2. 5 mg and 35 mg of lisinopril in patients with systolic heart failure, showed that the higher dose of lisinopril had outcomes at least as favorable as the lower dose During baseline-controlled clinical trials, in patients with systolic heart failure receiving digitalis and diuretics, single doses of lisinopril resulted in decreases in pulmonary capillary wedge pressure, systemic vascular resistance and blood pressure accompanied by an increase in cardiac output and no change in heart rate.
The management of acute cardiac insufficiency may involve the use of lisinopril in combination with digitalis and diuretics to reduce signs and symptoms of heart failure, such as edema, rales, paroxysmal nocturnal dyspnea, and jugular venous distention.
- The dose of lisinopril used in clinical studies for heart failure was up to 20 mg daily.
- Key benefits of lisinopril in heart failure include:
- Reduction in signs and symptoms of heart failure
- Decrease in pulmonary capillary wedge pressure, systemic vascular resistance, and blood pressure
- Increase in cardiac output with no change in heart rate 2
From the Research
Management of Acute Cardiac Insufficiency
The management of acute cardiac insufficiency involves several treatment options, including:
- Loop diuretics, such as furosemide, to improve haemodynamic parameters and dyspnoea due to congestion 3
- Nitrate derivatives, such as trinitrine and isosorbide dinitrate, to improve certain haemodynamic parameters, reduce blood pressure, and increase coronary flow 3, 4
- Non-invasive ventilation to improve physiological parameters, although its effect on mortality is unclear 3
- Inotropes, such as dopamine, dobutamine, and milrinone, to improve symptoms and haemodynamic parameters in patients with cardiogenic shock, but with a potential increase in mortality 3
- Oxygen therapy, although its clinical value has not been assessed comparatively in acute heart failure 3
Treatment Goals
The primary goal of treatment is to improve symptoms, such as dyspnoea, and to reduce the risk of mortality. Treatment should be individualized based on the patient's blood pressure, renal status, and previous use of loop diuretics 3.
Timing of Treatment
Early administration of furosemide has been associated with improved oxygenation in patients with acute heart failure 5. The door-to-furosemide time, defined as the time from patient arrival at the hospital to the first intravenous dose of furosemide, is an important factor in determining treatment outcomes.
Prehospital Therapy
Prehospital therapy for acute congestive heart failure includes the use of nitroglycerin, diuretics, and morphine, although these agents should be used with caution due to the risk of misdiagnosis and deleterious consequences 6. Noninvasive positive pressure ventilation methods are also effective adjuncts to current treatment, but their mode of delivery presents technical challenges.
Vasodilators
Vasodilators, such as nitroprusside, nitroglycerin, and nesiritide, are recommended for use in addition to diuretics to achieve hemodynamic and symptomatic improvement in patients with acute heart failure 4. However, the safety profiles of these drugs should be carefully considered.