What is the treatment for acute heart failure (AHF)?

From the Guidelines

Acute heart failure treatment requires immediate intervention with a combination of medications and supportive care, prioritizing decongestion, guideline-directed oral medical therapies, and risk stratification, as highlighted in the most recent study 1.

Initial Management

Initial management includes:

• Intravenous diuretics, typically furosemide at 20-40mg IV bolus, to reduce fluid overload and relieve congestion
• Oxygen therapy to maintain oxygen saturation above 90%
• Vasodilators such as nitroglycerin to reduce preload and afterload, improving cardiac output
• In cases of hypotension with evidence of end-organ hypoperfusion, inotropic agents like dobutamine or milrinone may be required

Underlying Causes

Underlying causes such as arrhythmias, acute coronary syndromes, or valvular problems must be identified and addressed.

Guideline-Directed Oral Medical Therapies

Once stabilized, patients should transition to oral heart failure medications including:

• ACE inhibitors/ARBs
• Beta-blockers
• Aldosterone antagonists
• Sodium-glucose co-transporter 2 inhibitors (SGLT2i), which have been shown to be beneficial in AHF patients 1

Fluid and Sodium Restriction

Fluid and sodium restriction (typically 1.5-2L fluid daily and <2g sodium) is important during recovery.

Cardiogenic Shock

Cardiogenic shock, the most severe form of AHF, requires early revascularisation and improvement of mechanical devices, as well as the use of vasopressors such as noradrenaline to increase blood pressure and ensure blood supply to vital organs 1. The aim of therapy of AHF is to correct hypoxia and increase cardiac output, renal perfusion, sodium excretion, and urine output, as stated in the European Society of Cardiology guidelines 1.

From the FDA Drug Label

Dobutamine Injection, USP is indicated when parenteral therapy is necessary for inotropic support in the short-term treatment of patients with cardiac decompensation due to depressed contractility resulting either from organic heart disease or from cardiac surgical procedures Nitroglycerin Injection is indicated for treatment of peri-operative hypertension; for control of congestive heart failure in the setting of acute myocardial infarction; Acute heart failure treatment options include:

• Dobutamine (IV) for inotropic support in the short-term treatment of patients with cardiac decompensation due to depressed contractility 2
• Nitroglycerin (IV) for control of congestive heart failure in the setting of acute myocardial infarction 3

From the Research

Treatment Options for Acute Heart Failure

• The treatment of acute heart failure syndromes (AHFS) typically involves the use of diuretics, vasodilators, and inotropes 4.
• Diuretics, such as furosemide, are commonly used to improve symptoms and reduce volume overload in patients with AHFS 5, 6.
• Vasodilators, including nitroglycerin and nitroprusside, can help to reduce blood pressure and improve cardiac hemodynamics 4, 7.
• Inotropes, such as dobutamine and dopamine, may be used in patients with low cardiac output, but their use is associated with an increased risk of adverse effects, including arrhythmias and mortality 4, 7.

Timing and Dosing of Treatment

• Early administration of furosemide has been shown to be associated with improved oxygenation in patients with acute heart failure 5.
• The optimal initial dose of intravenous diuretics is unclear, but a study found that treatment with a lower than guideline-recommended dose was associated with longer hospital stay, while a higher than recommended dose was associated with increased 60-day mortality 8.
• The dose of loop diuretics should be adjusted based on clinical response, renal status, and previous use of a loop diuretic 7.

Monitoring and Management

• Patients with acute heart failure require close monitoring, particularly when receiving treatment with vasodilators or inotropes 7.
• Non-invasive ventilation may be used in some patients, but its use is not appropriate for all patients and requires careful consideration of the potential benefits and risks 7.
• Oxygen therapy is usually recommended in cases of hypoxemia, but its clinical value has not been fully assessed in acute heart failure 7.