Covers the emergency treatment of acute heart failure, starting with the bedside questions of congestion and perfusion that guide drug choice, then treating the underlying cause, general measures and ventilation, and loop diuretic dosing with response checks. It goes on to vasodilators, inotropes and vasopressors with dose tables, cardiogenic shock and mechanical support devices, and ends with a profile-based treatment table and post-discharge care.
Topic 22 of 139 in the MU Sofia syllabus for Internal Diseases and Therapy (Medicine, Years 4 and 5). The free AceMed note covers it in 10 sections, about 978 words (10 min of reading), with 15 flashcards.
In this note
Reminders
Treat the cause at once (CHAMPIT)
General measures
Loop diuretics
Vasodilators
Inotropes and vasopressors
Other drugs
Cardiogenic shock
Treatment by clinical profile
Before and after discharge
Reminders
Acute heart failure (AHF) is an emergency: treatment starts while the diagnosis is being completed (European Society of Cardiology, ESC 2021, with the 2023 focused update).
Two bedside questions guide the drugs: is the patient congested (wet or dry) and perfused (warm or cold)? Systolic blood pressure (SBP) decides between vasodilators and inotropes.
Phases: immediate (stabilise breathing and circulation, find the cause, relieve congestion, restore perfusion) → in hospital (complete decongestion, protect kidneys and other organs) → before and after discharge (start oral disease-modifying drugs, early follow-up).
General measures
Sit the patient upright with the legs hanging down (reduces venous return).
Monitor the electrocardiogram (ECG), oxygen saturation (SpO₂), blood pressure, respiratory rate, urine output and daily weight; creatinine, urea and electrolytes every day while on IV treatment. A bladder catheter is not routine.
Oxygen only if SpO₂ < 90% or PaO₂ < 60 mmHg (arterial oxygen tension, 8 kPa); routine oxygen in non-hypoxaemic patients causes vasoconstriction and lowers cardiac output. Aim for SpO₂ 94–98% (88–92% in hypercapnic chronic obstructive pulmonary disease).
Non-invasive positive pressure ventilation (continuous positive airway pressure, CPAP, or bilevel pressure support, BiPAP) in respiratory distress (respiratory rate > 25/min, SpO₂ < 90%), started as early as possible: less work of breathing, lower preload and left ventricular afterload, fewer intubations. Start positive end-expiratory pressure (PEEP) at 5–7.5 cmH₂O and titrate to about 10. It can lower blood pressure.
Intubation for respiratory failure (PaO₂ < 60 mmHg, arterial carbon dioxide tension PaCO₂ > 50 mmHg and pH < 7.35) not managed non-invasively, exhaustion or coma.
Thromboprophylaxis with low-molecular-weight heparin (e.g. enoxaparin 40 mg subcutaneously daily) unless already anticoagulated or contraindicated.
Opioids (morphine 2.5–5 mg IV slowly, with an antiemetic) are no longer routine: they are linked with more ventilation and higher mortality. Keep them for severe pain or distress, and watch for respiratory depression.
Continue oral heart failure (HF) drugs where possible: reduce or pause β-blockers in shock or bradycardia, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor–neprilysin inhibitor (ARNI) in hypotension, hyperkalaemia or acute kidney injury.
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