What are the medications used to treat acute decompensated heart failure?

From the Guidelines

The primary medications used to treat acute decompensated heart failure include intravenous diuretics, vasodilators, and inotropes, with loop diuretics such as furosemide being first-line therapy to reduce fluid overload and relieve congestion. The initial recommended dose of furosemide should be 20–40 mg i.v. (or equivalent) for patients with new-onset AHF or those with chronic, decompensated HF not receiving oral diuretics, and at least equivalent to the oral dose for those on chronic diuretic therapy 1.

Key Medications

• Diuretics:
  • Loop diuretics like furosemide are recommended to improve symptoms, with monitoring of symptoms, urine output, renal function, and electrolytes during use 1.
  • The dose and duration should be adjusted according to the patient's symptoms and clinical status 1.
• Vasodilators:
  • Intravenous vasodilators like nitroglycerin or nitroprusside can be used for symptomatic relief in AHF with systolic blood pressure >90 mmHg and without symptomatic hypotension 1.
  • They should be considered as initial therapy in patients with hypertensive AHF to improve symptoms and reduce congestion 1.
• Inotropic agents:
  • Short-term, intravenous infusion of inotropic agents like dobutamine, dopamine, levosimendan, or phosphodiesterase III inhibitors may be considered in patients with hypotension and/or signs of peripheral hypoperfusion to maintain end-organ function 1.
  • However, inotropic agents are not recommended unless the patient is symptomatically hypotensive or hypoperfused due to safety concerns 1.

Additional Considerations

• Morphine may be used cautiously for anxiety and dyspnea, but its routine use is not recommended due to potential harm 1.
• Oxygen therapy should be administered to maintain saturation above 90%.
• Treatment should be individualized based on the patient's hemodynamic profile, with close monitoring of vital signs, urine output, and electrolytes to guide therapy adjustments and prevent complications.
• Thrombo-embolism prophylaxis is recommended in patients not already anticoagulated and with no contraindication to anticoagulation to reduce the risk of deep venous thrombosis and pulmonary embolism 1.

From the FDA Drug Label

Milrinone Lactate Injection is indicated for the short-term intravenous treatment of patients with acute decompensated heart failure. The medications used to treat acute decompensated heart failure include:

• Milrinone (IV) 2 These patients may also be receiving other medications such as:
• Digoxin
• Diuretics as part of their treatment regimen.

From the Research

Medications for Acute Decompensated Heart Failure

The following medications are used to treat acute decompensated heart failure:

• Diuretics, including:
  • Loop diuretics such as furosemide 3, 4, 5, 6, 7
  • Thiazide diuretics such as metolazone 3, 7
  • Potassium-sparing diuretics such as spironolactone 3, 7
• Vasodilators, including:
  • Nitroglycerin 4, 5, 6
  • Nitroprusside 4, 5, 6
  • Nesiritide 4, 5, 6
• Inotropes, including:
  • Dobutamine 4, 5, 6
  • Milrinone 4, 5, 6
• Aquaretics, including:
  • Tolvaptan 3, 7

Diuretic Strategies

Diuretic strategies for acute decompensated heart failure include:

• Early, aggressive administration of a loop diuretic 7
• Initial furosemide dose of 2-2.5 times the patient's home dose 7
• Addition of an adjunctive diuretic such as thiazide or acetazolamide if congestion persists 7
• Continuous infusion of furosemide if decongestion targets are not met 7

Treatment Goals

The treatment goals for acute decompensated heart failure are to:

• Decrease congestion 5
• Decrease afterload 5
• Decrease neurohormonal activation 5
• Improve hemodynamics and symptoms 5
• Reduce in-hospital events, re-hospitalizations, and mortality 5