From the Guidelines
Acute congestive heart failure requires immediate medical attention, and the most recent guidelines recommend initial management with oxygen therapy, intravenous diuretics, and vasodilators. According to the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1, diuretics are a cornerstone in the treatment of patients with acute heart failure (AHF) and signs of fluid overload and congestion. The initial approach to congestion management involves intravenous diuretics with the addition of vasodilators for dyspnea relief if blood pressure allows.
Key Components of Management
- Oxygen therapy to relieve symptoms related to hypoxemia
- Intravenous diuretics, such as furosemide, to reduce fluid overload and congestion
- Vasodilators, such as nitroglycerin, to reduce preload and afterload
- Inotropic agents, such as dobutamine, for patients with low cardiac output
- ACE inhibitors, such as enalapril, and beta-blockers, such as metoprolol, to reduce morbidity and mortality
Monitoring and Adjustments
- Continuous monitoring of vital signs, urine output, daily weights, and electrolytes to guide therapy
- Adjustments to diuretic dose and addition of second diuretic or continuous infusion of loop diuretic as needed to relieve congestion
- Monitoring for signs of hypoperfusion and hypotension, and adjustment of therapy accordingly
Underlying Cause Identification and Treatment
- Identification and treatment of underlying causes of heart failure, such as arrhythmias, coronary artery disease, or valvular problems
- Education on medication adherence, symptom recognition, and lifestyle modifications to prevent recurrence and improve outcomes
The 2016 ESC guidelines 1 provide the most recent and highest quality evidence for the management of acute congestive heart failure, and should be followed to optimize patient outcomes.
From the FDA Drug Label
The Systolic Heart Failure Treatment with the I f Inhibitor Ivabradine Trial (SHIFT) was a randomized, double-blind trial comparing ivabradine and placebo in 6,558 adult patients with stable New York Heart Association (NYHA) class II to IV heart failure, left ventricular ejection fraction ≤ 35%, and resting heart rate ≥ 70 bpm SHIFT demonstrated that ivabradine reduced the risk of the combined endpoint of hospitalization for worsening heart failure or cardiovascular death based on a time-to-event analysis (hazard ratio: 0.82,95% confidence interval [CI]: 0.75,0.90, p < 0. 0001)
- Ivabradine is used in the treatment of heart failure to reduce the risk of hospitalization for worsening heart failure or cardiovascular death.
- The SHIFT trial 2 showed that ivabradine reduced the risk of hospitalization for worsening heart failure.
- Dobutamine 3 is indicated for inotropic support in the short-term treatment of patients with cardiac decompensation due to depressed contractility.
- For acute congestive heart failure, dobutamine may be used for short-term treatment, but ivabradine is not indicated for acute treatment, it is used for long-term treatment to reduce the risk of hospitalization.
From the Research
Treatment Options for Acute Congestive Heart Failure
- Loop diuretics, such as furosemide, are commonly used to improve symptoms of acute congestive heart failure (ACHF) by reducing fluid overload and improving oxygenation 4, 5.
- Nitrates, including nitroglycerin, are vasodilators that can help reduce blood pressure and improve cardiac output in patients with ACHF 6, 5, 7.
- Noninvasive ventilation (NIV) may be used to support patients with ACHF, particularly those with acute cardiogenic pulmonary edema (ACPE) or chronic obstructive pulmonary disease (COPD) 8, 5.
Administration and Dosage
- Early administration of furosemide (within 60 minutes of hospital arrival) has been associated with improved oxygenation in patients with ACHF 4.
- The dose of furosemide should be adjusted based on clinical response, renal status, and previous use of loop diuretics 5.
- Intravenous nitroglycerin can be administered as a bolus dose (1mg) in patients with hypertension and acute respiratory distress, with repeat doses as needed 7.
Safety and Efficacy
- The use of nitrates and loop diuretics in ACHF has been shown to improve symptoms and hemodynamic parameters, but their effect on mortality is unclear 4, 6, 5.
- NIV has been shown to improve physiological parameters in patients with ACHF, but its impact on mortality is uncertain 8, 5.
- Prehospital administration of intravenous nitroglycerin has been found to be feasible, effective, and safe in patients with ACHF and acute pulmonary edema 7.