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Management of Heart Failure in ED

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Management of Heart Failure in the ED Setting:
An Evidence-Based Review of the Literature
J Emerg Med, 2018 Sep 26.
doi: 10.1016/j.jemermed.2018.08.002

Publicado en: Salud y medicina
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Management of Heart Failure in ED

  1. 1. Management of Heart Failure in the ED Setting: An Evidence-Based Review of the Literature J Emerg Med, 2018 Sep 26. doi: 10.1016/j.jemermed.2018.08.002
  2. 2. Why is this topic important? Acute heart failure (AHF) exacerbation is a common presentation to the ED, with the potential to cause significant morbidity and mortality. It is important to tailor treatments to the appropriate type of heart failure.
  3. 3. What does this review attempt to show? This review provides an evidence-based summary of the current ED management of AHF.
  4. 4. Methods Searched PubMed and Google Scholar for articles using the keywords ‘‘heart failure,’’ ‘‘management,’’ ‘‘treatment,’’ and ‘‘emergency.’ A total of 129 articles were selected for inclusion in this narrative review.
  5. 5. Discussion The primary management of AHF includes hemodynamic stabilization and symptom relief. Initial management should focus on assessment and management of the patient’s airway, breathing, and circulation.
  6. 6. 1. Mild AHF Exacerbation with Systemic Overload 2. Hypertensive AHF with Pulmonary Edema 3. Hypotensive AHF with Cardiogenic Shock 4. High-Output Heart Failure
  7. 7. Mild AHF Exacerbation with Systemic Overload
  8. 8. A diuretic (e.g., furosemide) can be provided at an i.v. dose of 1–2 times the patient’s known oral dose (furosemide at 20–40 mg i.v. or bumetanide at 1 mg i.v.), with diuresis typically occurring within 30– 60 min of i.v. administration. Decisions on bolus or continuous infusion and high- vs. low-dose strategies remain controversial.
  9. 9. There is variation in the recommendations for high- vs. low-dose furosemide. Patients receiving high-dose furosemide have demonstrated a trend toward higher rates of diuresis and improved overall outcomes, but they also experience increases in creatinine at greater rates.
  10. 10. Morphine is not recommended, as it is associated with an increased risk of mortality and need for ICU admission when it is given in AHF.
  11. 11. Ultrafiltration (UF) should be reserved for patients who are refractory to standard diuretic therapy. Compared with standard diuresis, UF controls fluid removal rate and may remove more total body sodium.
  12. 12. Hypertensive AHF with Pulmonary Edema
  13. 13. The primary focus of treatment for these patients includes respiratory support with noninvasive positive pressure ventilation (NIPPV) and vasodilators (specifically, nitrates), followed by diuretics if the patient is systemically volume overloaded.
  14. 14. NIPPV increases intra-thoracic pressure, thereby decreasing preload and lowering pulmonary interstitial fluid, as well as decreasing the work of breathing.
  15. 15. Nitrates rapidly reduce preload at lower doses and systemic afterload at higher doses. Initial sublingual NTG 0.4 mg per dose. i.v. NTG should be reserved for cases where the SBP remains > 160 mmHg Nitrates are contraindicated in patients who have recently used phosphodiesterase-5 inhibitors (e.g.,sildenafil, vardenafil), who have LV obstruction, or who are hypotensive.
  16. 16. Bolus doses of i.v. NTG have been demonstrated to be safe and associated with improved outcomes. NTG 0.5-2 mg i.v. bolus every 3 min, with decreased mortality, rates of intubation, and need for ICU admission. Initiating i.v. NTG at doses > 0.1 mg/min with rapid titration to patient response.
  17. 17. Hypotensive AHF with Cardiogenic Shock
  18. 18. If patients with AHF present with reduced EF and a low BP, immediate resuscitation is required with initiation of inotropic agents. A small fluid bolus (i.e., 250–500 mL) is recommended prior to initiating an inotropic agent.
  19. 19. Norepinephrine may be initially utilized to increase BP and preload in the presence of hypotension (similar to septic shock). It can be used in conjunction with dobutamine to increase cardiac output.
  20. 20. NIPPV should be considered in patients with respiratory distress and cardiogenic shock. NIPPV may further reduce preload and afterload, causing acute decompensation. Endotracheal intubation.
  21. 21. Mechanical circulatory support (MCS) should be considered in patients with persistent cardiogenic shock, if immediate stabilization is required to provide recovery of the cardiac system, if time is required for definitive therapy. IABP, VAD, V-A ECMO.
  22. 22. High-Output Heart Failure
  23. 23. Disposition
  24. 24. More than 80% of AHF patients are admitted from the ED. Several studies suggest that the use of observation units is safe and reduces overall costs.
  25. 25. For patients with hemodynamic instability, significant systemic congestion, inadequate response to medical therapy, new-onset AHF, electrolyte disturbances, elevated BUN or creatinine, ischemia on ECG, or inability to follow up should be admitted.
  26. 26. Heart Failure Risk Scores
  27. 27. Ottawa Heart Failure Risk Scale History • Stroke or TIA • Intubation for respiratory distress Examination • Heart rate ≥ 110 on ED arrival • Saturation ≤ 90% on arrival • Heart rate ≥ 110 during 3-min walk test (or too ill) Investigations • New ischemia on ECG • BUN ≥ 33 mg/dL • Serum CO2 ≥ 35 mEq/L • Troponin I/T meeting criteria for MI • NT-proBNP ≥ 5000 ng/L
  28. 28. Emergency Heart Failure Mortality Risk Grade • Age • Systolic BP (triage or initial) • Heart rate (triage or initial) • Oxygen saturation (lowest triage or initial) • Creatinine • Potassium • Transportation by EMS • Positive troponin • Active malignancy • On outpatient metolazone
  29. 29. Special Consideration– Atrial Fibrillation with Acute Heart Failure
  30. 30. If the dysrhythmia is the primary cause of heart failure with hemodynamic instability, then the patient should undergo cardioversion. If the dysrhythmia is not the primary cause of the exacerbation, immediate cardioversion may be associated with adverse outcomes. Digoxin can be utilized in patients with decompensated heart failure, with doses 0.25 mg i.v. at one time, up to a maximum of 1.5 mg over 1 day.