View source for Congestive heart failure acute pharmacotherapy

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| [[File:Siren.gif|30px|link= Congestive heart failure resident survival guide]]|| <br> || <br>
| [[Acute decompensated heart failure resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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{{Congestive heart failure}}
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{{SK}} Acute heart failure; AHF; Heart failure; HF; BTB;  bridge to bridge; BTD; bridge to decision; BTR; bridge to recovery;

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]).  ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of [[fluid in the lung]]).  Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]].  ADHF associated with a poor prognosis if not treated aggressively.  Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability.  The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]].  Some of the mainstays of [[chronic heart failure therapy]] are not initiated acutely ([[ACE inhibtors]],[[beta blockers]] and [[digoxin]]).










== 2022 AHA/ACC/HFSA Heart Failure Guideline Hospitalization of patients with acute heart failure ==

=== Assessment of Patients Hospitalized With Decompensated HF ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1. I'''n patients hospitalized with HF, the severity of congestion and adequacy of perfusion should be assessed to guide triage and initial therapy (Level of Evidence C-LD).
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In patients hospitalized with HF, the common precipitating factors and the overall patient trajectory should be assessed to guide appropriate therapy (Level of Evidence C-LD).
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' For patients admitted with HF, treatment should address reversible factors, establish optimal volume status, and advance GDMT toward targets for outpatient therapy (Level of Evidence C-LD).
|}
<ref name="pmid35363500">{{cite journal| author=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM | display-authors=etal| title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 18 | pages= e876-e894 | pmid=35363500 | doi=10.1161/CIR.0000000000001062 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35363500  }}</ref>

=== Maintenance or Optimization of GDMT During Hospitalization ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with HFrEF requiring hospitalization, preexisting GDMT should be continued and optimized to improve outcomes, unless contraindicated (Level of Evidence B-NR)<nowiki>''</nowiki>.
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In patients experiencing a mild decrease of renal function or asymptomatic reduction of blood pressure during HF hospitalization, diuresis, and other GDMT should not routinely be discontinued (Level of Evidence B-NR)<nowiki>''</nowiki>.
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' In patients with HFrEF, GDMT should be initiated during hospitalization after clinical stability is achieved. (Level of Evidence B-NR).
|-
| bgcolor="LightGreen" |<nowiki>''</nowiki>4. In patients with HFrEF, if discontinuation of GDMT is necessary during hospitalization, it should be reinitiated and further optimized as soon as possible (Level of Evidence B-NR)<nowiki>''</nowiki>
|}
<ref name="pmid35363500" />

=== Diuretics in Hospitalized Patients: Decongestion Strategy ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' Patients with HF admitted with evidence of significant fluid overload should be promptly treated with intravenous loop diuretics to improve symptoms and reduce morbidity (Level of Evidence B-NR)<nowiki>''</nowiki>.
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' For patients hospitalized with HF, therapy with diuretics and other guideline-directed medications should be titrated with the goal to resolve clinical evidence of congestion to reduce symptoms and rehospitalizations(Level of Evidence B-NR)<nowiki>''</nowiki>.
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' For patients requiring diuretic treatment during hospitalization for HF, the discharge regimen should include a plan for adjustment of diuretics to decrease rehospitalizations (Level of Evidence B-NR).
|}
<ref name="pmid35363500" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |"4'''.''' In patients hospitalized with HF when diuresis is inadequate to relieve symptoms and signs of congestion, it is reasonable to intensify the diuretic regimen using either: a. higher doses of intravenous loop diuretics or addition of a second diuretic''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>
|}
<ref name="pmid35363500" />

=== Parenteral Vasodilation Therapy in Patients Hospitalized With HF ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |"1'''.''' In patients who are admitted with decompensated HF, in the absence of systemic hypotension, intravenous nitroglycerin or nitroprusside may be considered as an adjuvant to diuretic therapy for relief of dyspnea''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>
|}
<ref name="pmid35363500" />

=== VTE Prophylaxis in Hospitalized Patients ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients hospitalized with HF, prophylaxis for VTE is recommended to prevent venous thromboembolic disease (Level of Evidence B-R)<nowiki>''</nowiki>.
|}
<ref name="pmid35363500" />

''Subcutaneous low-molecular-weight heparin, unfractionated heparin, fondaparinux, or approved DOAC are used for the prevention of clinically symptomatic deep vein thrombosis and pulmonary embolism<ref name="pmid35363500" />.'' 

=== Evaluation and Management of Cardiogenic Shock ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with cardiogenic shock, intravenous inotropic support should be used to maintain systemic perfusion and preserve end-organ performance(Level of Evidence B-R)<nowiki>''</nowiki>.
|}
<ref name="pmid35363500" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 2'''.''' In patients with cardiogenic shock, temporary MCS is reasonable when an end-organ function cannot be maintained by pharmacologic means to support cardiac function (Level of Evidence B-NR)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 3. In patients with cardiogenic shock, management by a multidisciplinary team experienced in shock is reasonable(Level of Evidence C-NR)<nowiki>''</nowiki>
|}
<ref name="pmid35363500" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 4'''.''' In patients presenting with cardiogenic shock, placement of a PA line may be considered to define hemodynamic subsets and appropriate management strategies (Level of Evidence B-NR)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 5. For patients who are not rapidly responding to initial shock measures, triage to centers that can provide temporary MCS may be considered to optimize management (Level of Evidence C-LD)<nowiki>''</nowiki>
|}
<ref name="pmid35363500" />

=== Integration of Care: Transitions and Team-Based Approaches ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' n patients with high-risk HF, particularly those with recurrent hospitalizations for HFrEF, referral to multidisciplinary HF disease management programs is recommended to reduce the risk of hospitalization(Level of Evidence B-R)<nowiki>''</nowiki>.
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In patients hospitalized with worsening HF, patient-centered discharge instructions with a clear plan for transitional care should be provided before hospital discharge(Level of Evidence B-NR)<nowiki>''</nowiki>.
|}

<ref name="pmid35363500" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 3'''.''' In patients hospitalized with worsening HF, participation in systems that allow benchmark-ing to performance measures is reasonable to increase use of evidence-based therapy, and to improve quality of care.(Level of Evidence B-NR)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 4. In patients being discharged after hospital-ization for worsening HF, an early follow-up, generally within 7 days of hospital discharge, is reasonable to optimize care and reduce rehospitalization (Level of Evidence B-NR)<nowiki>''</nowiki>
|}

<ref name="pmid35363500" />
==2021 ESC Guideline for management of [[acute heart failure]]==
<span style="font-size:85%">'''Abbreviations:'''
'''AHF:''' [[Acute heart failure]];
'''LMWH:''' [[Low-molecular-weight heparin]];
'''PaO2:''' [[Partial pressure of oxygen]] ;
'''SBP:''' [[Systolic blood pressure]];
'''SpO2:''' [[Transcutaneous oxygen saturation]];
</span>
<br>
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for initial treatment of acute heart failure'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support  ([[ 2021 ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Oxygen]] is recommended in [[hypoxic]] [[patients]] with  [[SpO2]]<90% or [[PaO2]] <60 mmHg<br>
❑ [[Intubation]] is recommended in the presence of progressive [[respiratory failure]] in spite of [[oxygen]] administration or non-invasive [[ventilation]]<br> 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support  ([[ 2021 ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[respiratory distress]] ([[respiratory rate]] >25 breaths/min, SpO2<90%), [[non-invasive]] [[positive pressure ventilation]] is recommended to decrease [[respiratory distress]] and reduce the rate of mechanical [[endotracheal intubation]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] :([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[loop diuretics]] are considered for all admitted [[patients]] with [[acute heart failure]] presented  with [[signs]], [[symptoms]] of [[fluid]] overload<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] : ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with resistant [[edema]] who do not respond to an increase in [[loop diuretic]] doses, combination of a [[loop diuretic]] with [[thiazide]] type [[diuretic]] should be considered <br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasodilators]]: ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In order to improve [[symptoms]] and reduce [[congestion]] in  [[patients]] with [[AHF]] and SBP >110 mmHg, [[vasodilators]] may be considered as initial therapy<br> 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Inotropic agents]] : ([[ESC guidelines classification scheme|Class 2b, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Inotropic]] agents may be considered in [[patients]] with [[SBP]] <90 mmHg and evidence of [[hypoperfusion]] without response to fluid challenge, to improve peripheral
[[perfusion]] and maintain [[end-organ]] function<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Inotropic]] agents ([[ESC guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑  Routinely administration of [[inotropic]] agents are not recommended , due to safety concerns, unless the [[patient]] has [[symptomatic hypotension]] and evidence of [[hypoperfusion]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasopressors]]: ([[ESC guidelines classification scheme|ClassIIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[cardiogenic shock]], a [[vasopressor]], preferably [[norepinephrine]], may be indicated to increase [[blood pressure]] and vital [[organ]] perfusion<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Anticoagulant therapy]]: ([[ESC guidelines classification scheme|ClassI, Level of Evidence A]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Thromboembolism prophylaxis]] such as [[LMWH]] is recommended in [[patients]] not already [[anticoagulated]] and no contraindication to [[anticoagulation]], to prevent the risk of [[deep venous thrombosis]] and [[pulmonary embolism]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Opiates]]: ([[ESC guidelines classification scheme|ClassIII, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Opiates]] is not routinely recommended, unless in selected [[patients]] with severe, intractable [[pain]] or [[anxiety]]<br>
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline
|- 
|}<ref name="pmid34447992">{{cite journal |vauthors=McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A |title=2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure |journal=Eur Heart J |volume=42 |issue=36 |pages=3599–3726 |date=September 2021 |pmid=34447992 |doi=10.1093/eurheartj/ehab368 |url=}}</ref>
===Pre-hospital setting===
*In the pre-hospital setting, [[AHF]] [[patients]] should be monitored by [[pulse oximetry]], [[BP]], [[heart rate]], [[respiratory rate]], and a continuous [[ECG]].
*[[Oxygen]] therapy may be given based on a clinical judgment unless [[oxygen saturation]] is <90% in which case it should be administered.
* Indication for [[non-invasive ventilation]]: 
*:[[Respiratory distress]]
*: [[Respiratory rate]] >25 breaths/min
* [[Oxygen saturation]] <90%
 
===In-hospital management===
*Specific causes of [[AHF]] should be searched including [[ACS]], [[ hypertensive emergency]], rapid [[arrhythmias]], severe [[bradycardia]], [[conduction disturbance]], acute [[valve regurgitation]], acute [[pulmonary embolism]], [[myocarditis]], [[tamponade]].
* After exclusion of these [[conditions]], which need to be treated, [[AHF]] should be managed according to the [[clinical]] presentations.

===Pre-discharge phase===
=== [[Oxygen]] therapy, [[ventilatory]] support===
*In [[AHF]], [[oxygen]] should not be used routinely in non-[[hypoxaemic]] [[patients]] due to  [[vasoconstriction]] and a reduction in [[cardiac output]].
* [[Oxygen]] therapy is recommended in [[patients]] with [[AHF]] SpO2 <90% or [[PaO2]] <60 mmHg to correct [[hypoxemia]]. 
*In [[chronic obstructive pulmonary disease]] ([[COPD]]), [[hyper-oxygenation]] may increase [[ventilation-perfusion mismatch]], suppress [[ventilation]] and
lead to [[hypercapnia]].
* During [[oxygen]] therapy, [[acid-base balance]] and [[SpO2]] should be monitored.
*[[Non-invasive positive pressure ventilation]], either continuous [[positive airway pressure]] and [[pressure]] support, improves [[respiratory failure]], increases [[oxygenation]] and [[pH]], and decreases the [[partial pressure]] of [[carbon dioxide]] ([[pCO2]]) and work of [[breathing]] and reduce the rate of [[endotracheal intubation]]. 
*  [[Non-invasive positive pressure ventilation ]] indicated to improve [[gas exchange]] and reduce the rate of [[endotracheal intubation]] in [[patients]] with:
:* [[Respiratory distress]] ([[respiratory rate]] >25 breaths/min
:* [[SpO2]] <90% 
*[[FiO2]] should be increased up to 100%, if needed, based on  [[oxygen saturation]] level.
*[[Blood pressure]] should be monitored regularly during [[non-invasive positive pressure ventilation]]. 
*The increase in intrathoracic pressure with [[non-invasive positive pressure ventilation]] may lead to reduction in  [[venous return]], right and [[left ventricular]] preload, [[cardiac output]] and [[BP]].
* In the setting of [[RV]] dysfunction, the increase in [[pulmonary vascular resistance]] and [[RV]] afterload may be present.
* [[Intubation]] is indicative if there is progressive [[respiratory failure]] despite [[oxygen]] administration or [[non-invasive ventilation]].

=== [[Diuretics]]===
*Intravenous [[diuretics]] are mainstay therapy of [[AHF]].
* Efficacy of [[diuretics]] are due to increase [[renal excretion]] of [[salt]] and [[water]] and reduce of [[fluid]] overload and [[congestion]].
* There was a greater relief of [[dyspnoea]], change in [[weight]] and net [[fluid]] loss (with no prognostic role for increases in serum [[creatinine]]) in the higher-dose regimen.
*High [[diuretic]] doses may associate with greater [[neurohormonal]] activation and electrolyte disturbance and poor [[outcomes]].
*  Treatment with [[diuretic]] should be started with an initial i.v. dose of [[furosemide]], or equivalent dose of [[bumetanide]] or [[torasemide]] to 1-2 times the daily oral dose taken by the [[patient]] before [[admission]]. 
*If the [[patient]] was not on oral [[diuretics]], a starting dose of 20-40 mg of [[furosemide]], or a bolus of 10-20 mg i.v [[torasemide]], can be used.
* [[Furosemide]] can be given as 2-3 daily boluses or as a continuous [[infusion]]. 
* Due to post-dosing [[sodium]] retention, daily single bolus administrations are not recommended.
* With continuous [[infusion]], a loading dose may be used to achieve steady-state earlier. 
* Response to [[diuretic]] should be evaluated shortly after the start of [[diuretic]] therapy and may be measured by performing spot urine [[sodium ]] content  after 2 or
6 h and/or by measuring the hourly [[urine output]].
* A satisfactory [[diuretic]] response can be considered as a [[urine sodium]] content >50-70 mEq/L at 2 h and/or by a [[urine output]] >100-150 mL/h during the first 6 h.
* If there is an inadequate [[diuretic]] response, the [[loop diuretic]] i.v. dose can be doubled, with a further assessment of [[diuretic ]] response.
* If the [[diuretic]] response remains insufficient including <100 mL hourly [[diuresis]]in spite of doubling [[loop diuretic]] dose,  concomitant administration of other [[diuretics ]] such as  [[thiazides]] or [[metolazone]] or [[acetazolamide]] , may be considered. 
*[[Serum]] [[electrolytes]] and [[renal function]] should be carefully monitored.
* Low doses of [[loop diuretics]], with frequent doses may be less likely to cause [[dehydration]] or increase in serum [[creatinine]]. 
* Oral treatment should be started after [[congestion ]] relief.
* Oral [[loop diuretics]] are continued at the lowest dose possible to avoid [[congestion]].
* Discharge of hospital with persistent [[congestion]] is a major predictor of increased deaths and [[rehospitalizations]].
* Appropriate long-term diuretic dose should be established before discharge.
===[[Vasodilators]]===
*Intravenous [[vasodilators]], namely [[nitrates]] or [[nitroprusside]]  with the effect of dilating venous and [[arterial]] [[vessels]] leading to a reduction in [[venous]] return to the [[heart]], less [[congestion]], lower [[afterload]], increased [[stroke volume]] and consequent relief of [[symptoms]].
*[[Nitrates]] act mainly on [[peripheral veins]] whereas the effect of [[nitroprusside]] is dilation of [[arterial]] and [[venule]].
* [[vasodilators]]  may be more effective than [[diuretics]] when acute [[pulmonary edema]] is due to increased [[afterload]] and fluid [[redistribution]] to the [[lungs]] in the absence or with minimal fluid accumulation. 
* Intravenous [[vasodilators]] may be considered to relieve AHF [[symptoms ]] when [[SBP]] is >110 mmHg. 
* They may be started at low doses and uptitrated to achieve clinical improvement and [[BP]] control.
* [[Nitrates]] are generally administered with an initial bolus followed by continuous [[infusion]] or repeated boluses.
* [[ Nitroglycerine]] can be given as 1-2 mg boluses in severely [[hypertensive]] [[patients]] with acute [[pulmonary edema]].
* [[BP]] monitoring is needed to avoid [[hypotension]] due to an excessive decrease in [[preload]] and [[afterload]].
* Caution should be exercised in [[patients]] with [[LVH]] and/or severe [[aortic stenosis]].
* [[Hemodynamic parameters]] should be monitored in [[patients]] with [[left ventricular]]  [[systolic dysfunction]] and [[aortic stenosis ]] when [[vasodilators]] are given.

===[[Inotropes]]===
* [[Inotropes]] is recommended in [[patients]] with low [[cardiac output]] and [[hypotension]], [[left ventricular systolic dysfunction]] and poor [[organ perfusion]].
* [[Inotropes]] should be started under [[monitoring]].
* Common side effects of [[inotropes]] with [[adrnergic]] mechanism including [[sinus tachycardia]], increase [[ventricular rate]] in [[patients]] with [[AF]], induced [[myocardial ischemia]] and [[arrhythmias]], and increase [[mortality]].
* [[Levosimendan]] or [[type-3-phosphodiesterase inhibitors]] may be preferred over [[dobutamine]] for [[patients]] on [[beta-blockers]].
* [[Type-3-phosphodiesterase inhibitors]] or [[levosimendan]] may lead to [[peripheral vasodilation]] and [[hypotension]], especially when administrated at high doses.
===[[Vasopressors]]===
* [[Norepinephrin]] may be preferred in [[patients]] with severe [[hypotension]], due to [[peripheral vasoconstriction]], to increase [[perfusion ]] to vital [[organs]] at the expense of an increase in [[left ventricular]] [[afterload]].
*In [[patients]] with advanced [[HF]] and [[cardiogenic shock]], a combination of [[norepinephrine]] and [[inotropic]] agents may be considered.
*  In some studies, the use of [[norepinephrine]] was the first choice, compared with [[dopamine]] or [[epinephrine]].
*[[Dopamine]] was preferred to  [[norepinephrine]] as a first-line [[vasopressor]] therapy in [[patients]] with [[shock]].
* Use of [[dopamin]] was associated with [[arrhythmic]] events and with ahigher [[mortality]] in [[patients]] with [[cardiogenic shock]] but not in those with [[hypovolaemic]] or [[septic shock]].
* Use of [[epinephrine]] in comparison  with [[norepinephrine]] in [[patients]] with [[cardiogenic shock]] due to acute [[MI]] was associated with higher [[heart rate]]and [[lactic acidosis]] and [[mortality]].

===[[Opiates]]===
*[[Opiates]] relieve [[dyspnea]] and [[anxiety]]. 
*They may be used as sedative agents during [[non-invasive positive pressure ventilation]] to improve [[patient]] adaptation. 
*Dose-dependent side effects including [[nausea]], [[hypotension]], [[bradycardia]], and [[respiratory depression]]. 
* Administration of [[morphine]]  is associated with a higher frequency of [[mechanical ventilation]], prolonged [[hospitalization]], more [[intensive care unit admissions]], and increased [[mortality]].
*So, routine use of [[opiates]] in [[AHF]] is not recommended.
* Use of [[morphine]] is recommended in selected [[patients]] with severe/intractable [[pain]] or [[anxiety]] or in the setting of [[palliation]].
===[[ Digoxin]]===
*[[Digoxin]] should be considered in patients with [[AF]] with a rapid [[ventricular rate ]] (>110 b.p.m.) despite [[beta-blockers]].
* [[Digoxin]] can be given in boluses of 0.25-0.5 mg i.v., if not used previously.
* In [[patients]] with comorbidities (i.e. [[CKD]]) or other factors affecting [[digoxin]] metabolism (including other drugs) and/or the [[elderly]], the maintenance dose may be difficult to estimate.
* [[Serum]] concentration of [[digoxin]] should be measured.

===[[Thromboembolism]] prophylaxis===
*[[Thromboembolism]] prophylaxis with [[heparin]],  [[low-molecular weight heparin]] or another [[anticoagulant]] is recommended, unless contraindicated or existing therapy with oral [[anticoagulants]].
















{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[acute heart failure]] }}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Cardiogenic shock]], [[respiratory failure]]}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= NO| C02= Yes}}
{{Family tree | |!| | | | | |!| | | | | | | | | | | |}}
{{Family tree |  G1 | | | |  F2 | | | | | | | | | | |F2=
 [[Pharmacologic therapy]]
* [[Ventilatory support]]
* [[Mechanical circulatory support]]| G1= Identifying acute causes}}
{{Family tree | |!| | | | | | | | | | | | | | | | | | }}
{{Family tree |  G2 | | | | | | | | | | | | | | | |G2=
[[Acute Coronary syndrome]]
*[[Hypertension]] emergency
*[[Arrhythmia]]
*[[Mechanical]] causea 
*[[Pulmonary embolism]]
*[[Infections]]
*[[Tamponade]]}}
{{Family tree |,|^|-|-|.| | | | | | | | | | | | | | |}}
{{Family tree | Z1| | Z2| | | | | | | | | Z2=NO| |Z1= Yes}}
{{Family tree | |!| | |!| | | | | | | | | | | | | | | }}
{{Family tree | P1| |C  | | | | | | | | | | P1= Immediate initiation of specific treatment |C= Further treatment | | | | }}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline
|- 
|}<ref name="pmid34447992">{{cite journal |vauthors=McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A |title=2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure |journal=Eur Heart J |volume=42 |issue=36 |pages=3599–3726 |date=September 2021 |pmid=34447992 |doi=10.1093/eurheartj/ehab368 |url=}}</ref>



===Short-term [[mechanical circulatory support]]===
*In [[patients]] presenting with [[cardiogenic shock]], short-term [[MCS]] may be considered to increase [[cardiac output]] and support end-organ [[perfusion]]. 
*Short-term [[MCS]] can be used as a  [[bridge to recovery]] ([[BTR]]), [[bridge to decision]] (BTD) or [[bridge to bridge]] ([[BTB]]).
*The initial improvements in [[cardiac output]], [[BP]] and [[arterial]] [[lactate]] may be affected by significant [[complications]].
*Close monitoring of [[hemodynamics]] and [[lactate]] as the markers of [[end-organ damage]] may improve [[survival]].
* Use of The [[Intra-aortic Balloon Pump]] in [[Cardiogenic shock]] was not associated with the reduced long-term [[mortality]] compared with [[medical therapy]].
* [[IABP]] is not routinely recommended in [[cardiogenic shock]] post-[[MI]].
* However, it may still be considered in [[cardiogenic shock]], especially if not due to [[ACS]], and refractory to drug therapy, as a BTD, [[BTR]], or [[BTB]].
*  [[Patients]] with [[cardiogenic shock]] or [[cardiac arrest]] treated with [[venoarterial ]] [[VA-ECMO]] showed favorable [[outcome]].
* In cases of [[fulminant myocarditis]] and other [[conditions]] causing severe [[cardiogenic shock]], [[VA-ECMO]] may also be considered.
* Depending on the severity of [[myocardial dysfunction]] and/or concomitant [[mitral regurgitation]] or [[aortic regurgitation]], [[VA-ECMO]] may increase [[LV]] afterload with an increase in [[LV end-diastolic pressure]] and [[pulmonary congestion]].
* In these cases, [[LV unloading]] such as [[Impella]] is considered.

==2021 ESC Guideline for management of [[pulmonary edema]]==

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with [[pulmonary edema]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01= [[Oxygen]] (Class I) or [[ventilatory support]] (Class IIa)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Systolic blood pressure]] ≥110 mmHg}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | }}
{{Family tree |  A6 | | | | | A7| | |A6= [[Loop diuretics]] (Class I) and/or [[vasodilators]] (Class IIb)|A7=[[Signs]] of [[hypoperfusion]] }}
{{Family tree | |:| | | | |,|-|^|-|.| | | |}}
{{Family tree | |:| | | | | A8| |A9 | | |A8=Yes|A9=NO}}
{{Family tree | |:| | | | |!| | | |!| | | }}
{{Family tree | |:| | | | |A10| |A11| |A10=[[Loop diuretics]] (Class I) and [[inotropes]]/[[vasopressors]](Class IIb)|A11=[[Loop diuretics]] (Class I)}}
{{Family tree | |`|-|-|-|-|v|-|-|-|'| | | | }}
{{Family tree | | | | | | | A12 | | | A12=[[Congestion]] relief}}
{{Family tree | | | | | |,|-|^|-|.| | |}}
{{Family tree | | | | | |A13| |A14| | |A13=Yes|A14=NO}}
{{Family tree | | | | | |!| | | |!| |}}
{{Family tree | | | | | |A15| |A16| | A15= Optimized [[medical therapy]]| A16= [[Renal replacement therapy]]
*[[ Mechanical circulatory support]]
* [[Palliative therapy]]}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline
|- 
|}


*[[Acute pulmonary edema]] is related to [[lung]] [[congestion]].
* Clinical characteristics include  [[dyspnea]] with [[orthopnea]], [[respiratory failure]] ([[hypoxemia]]-[[hypercapnia]]), [[tachypnea]] >25 breaths/min, and increased work of [[breathing]].
*Treatment including as follows:
* [[Oxygen]], given as [[continuous positive airway pressure]], non-invasive positive pressure-[[ventilation]] and/or high-flow nasal cannula
* [[Diuretics]]  
*[[Vasodilators]]  if [[systolic BP]] ([[SBP]]) is high, to reduce [[LV]] [[afterload]] 
*:: In the setting of [[acute pulmonary edema]] with low [[cardiac output]] state, [[inotropes]], [[vasopressors]], and/or [[MCS]] are indicated to restore [[organ]] [[perfusion]].

==2021 ESC Guideline for management of [[cardiogenic shock]]==

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01=Management of [[patients]] with [[cardiogenic shock]] }}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Acute coronary syndrome]] ([[ACS]]), [[mechanical complications]] }}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01=Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | }}
{{Family tree |   A5| | | |  A6 | | | A5=[[Emergency PCI]] or [[surgical]] treatment|A6=Identifying and treatment of other specific causes}}
{{Family tree | | |`|-|v|-|-|'| | }}
{{Family tree | | | | |A7 | | | | | A7=[[Oxygen]] therapy (Class I) or [[ventilatory]] support (Class IIa)
* [[Inotropes]], [[vasopressors]] (Class IIb)
* Short-term [[mechanical circulatory support]] (Class IIa)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | |A8 | | | | | A8=Improvement of [[hypoperfusion]] and [[organ]] dysfunction}}
{{Family tree | | |,|-|^|-|.| | | }}
{{Family tree | | | A9| |A10| | | | A9=Yes|A10=NO}}
{{Family tree | | | |!| | |!| | | }}
{{Family tree | | A11 | |A12| | | |A11=Weaning from [[inotropes]]/[[vasopressors]] and/or [[mechanical circulatory support]]
*Treatment of underlying etiology and [[medical therapy]] optimization (Class I )|A12=[[Mechanical circulatory support]](Class IIa)
*[[Renal replacement therapy]] (Class IIa)
*[[Palliative care]] }}

{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline
|- 
|}

==References==
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