See Pulmonary Edema or Sympathetic crashing acute pulmonary edema (SCAPE)
See Cardiogenic Shock
Inotropic Agents
Dobutamine generally first line
Milrinone if patient on beta-blockers
Consider in severe LV dysfunction and low output syndrome
Diminished peripheral perfusion and end organ damage
Vasodilatory treatment inadequate response or limited by symptomatic hypotension
Must have obvious evidence of elevated filling pressures
JVD, noncollapsing IVC, etc
Inotropes are not indicated in setting of preserved systolic function
Diminished peripheral perfusion and end organ damage
JVD, noncollapsing IVC, etc
UNLOAD+
Do not use with sildenafil, severe AS, or if right-sided MI
Start sublingual nitroglycerin 0.4mg delivered over 4 min = 0.10mg/min
If no improvement IV nitroglycerin drip, start 0.3-0.5mcg/kg/min, but may increase to 3-5mcg/kg/min
Keep BP >95
Consider nitroprusside 0.3 mcg/kg/min if hypertension or nitroglycerin ineffective
Keep BP >95
Hold if no symptoms of fluid overload
Give nitrates first
Give double home dose, or up to 2.5x dose.
If lasix 40mg po QD, then lasix 40-100mg IV
If lasix 40mg po QD, then lasix 40-100mg IV
CPAP/BiPAP
Increases intrathoracic pressure and thus reduces preload
Increases intrathoracic pressure and thus reduces preload
Afterload reduction
Enalaprilat at 0.004mg/kg as IVB or 1mg drip over 2hr
Avoid in pregnancy, hyperK+, angioedema
Avoid in pregnancy, hyperK+, angioedema
Decompensated HF
Digoxin and Amiodarone are the only medications indicated for use in decompensated HF for rate control if needed
Evidence suggests that treating rate in acutely ill patients including<unk>  leads to worse outcomes
Compensated HF (not acutely symptomatic from failure)
May benefit from a fib rate control, but calcium-channel blockers and beta-blockers first line, goal of < 85 bpm per RACE II trial
Diltiazem low and slow at 5mg/hr
AVOID in severe<unk>  failure, preexcitation syndrome
AVOID in significant hypotension
Metoprolol 2.5 - 5.0mg over 2 min, then q5 as needed to max of 15mg
Esmolol 0.5mg/kg bolus over 1 min, then 50 mcg/kg/min, may increase q30 min by 50 mcg/kg/min
Digoxin and Amiodarone are the only medications indicated for use in decompensated HF for rate control if needed
Evidence suggests that treating rate in acutely ill patients including<unk>  leads to worse outcomes
May benefit from a fib rate control, but calcium-channel blockers and beta-blockers first line, goal of < 85 bpm per RACE II trial
Diltiazem low and slow at 5mg/hr
AVOID in severe<unk>  failure, preexcitation syndrome
AVOID in significant hypotension
Metoprolol 2.5 - 5.0mg over 2 min, then q5 as needed to max of 15mg
Esmolol 0.5mg/kg bolus over 1 min, then 50 mcg/kg/min, may increase q30 min by 50 mcg/kg/min
AVOID in severe<unk>  failure, preexcitation syndrome
AVOID in significant hypotension
Anti-dysrhythmics other than digoxin and amiodarone
Calcium-channel blockers - worsen HF
NSAIDs - sodium retention, worsen toxicity of diuretics and ACE-I
Thiazolidinediones - worsen HF
Morphine - chart reviews show increased morbidity in ADHF patients
Congestive heart failure
Cardiovascular
Lung transplant complications
ACS
High-output heart failure
Acute Valve Dysfunction
Cirrhosis
Aortic Dissection