Internal Medicine

0521779407-01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:45

26 Acute Heart Failure

General Measures

■Usually more comfortable sitting upright with legs dangling

■Restore and maintain oxygenation: supplemental oxygen, non-

invasive positive pressure ventilation (BiPAP), mechanical ventila-

tion, morphine

■Reduce volume overload (preload): diuretics, nitrates, morphine,

nesiritide, ultrafiltration

■Reduce afterload: nitroprusside, nitroglycerin, nesiritide

■Improve cardiac function: positive inotropes (dobutamine, milri-

none), intra-aortic balloon counterpulsation, left ventricular assist

device

■Maintain blood pressure, renal perfusion: dopamine (low dose)

■Consider Swann-Ganz pulmonary artery catheter to measure cardiac

output, PCWP and vascular resistances and guide therapy, especially

if:

➣Cardiogenic shock/ near shock unresponsive to fluid challenge

➣Unresponsive pulmonary edema, especially with hypotension or

shock

➣Assist in diagnosis between cardiogenic and non-cardiogenic eti-

ology

specific therapy

Indications for Treatment

■Poor oxygenation

■Poor peripheral perfusion

■Poor central perfusion

■Volume overload

■Hypotension

Treatment Options

Including Side Effects and Contraindications: General info on drug

classes, check for more complete prescribing information

■Morphine: intravenous, subcutaneous (in mild cases)

➣Indication: Reduce preload, decrease anxiety and hyperadrener-

gic state

➣Side Effects and Complications: Decreased ventilatory drive with

possible CO2 retention, hypotension, paralytic ileus, toxic mega-

colon, seizures, somnolence, constipation, urinary retention,

dizziness, dry mouth, headache, nausea/ vomiting, rash.

➣Absolute Contraindications: Narcotic-induced pulmonary

edema, respiratory depression, paralytic ileus