Heart failure, acute

AHF acute heart failure, CHF chronic heart failure, CRF chronic renal failure, NEP neutral endopeptidase, ECE endothelin converting enzyme, PAH pulmonary arterial hypertension. 

Nicardipine hydrochloride 5-15 mg/hour IV 5-10 minutes 15-30 minutes, may exceed 4 hours Tachycardia, headache, flushing, local phlebitis Most hypertensive emergencies except acute heart failure use with caution with coronary ischemia... 

Labetalol hydrochloride 20-80 mg IV bolus every 10 minutes 5-10 minutes 3-6 hours Vomiting, scalp tingling, dizziness, bronchoconstriction, nausea, heart block, orthostatic hypotension Most hypertensive emergencies except acute heart failure... 

Treatment of acute heart failure targets relief of congestion and optimization of cardiac output utilizing oral or intravenous diuretics, intravenous vasodilators, and when appropriate, inotropes. 

The phrase acute heart failure (AHF) is used to signify either an acute decompensation of a patient with a history of chronic heart failure or to refer to a patient presenting with new-onset HF symptoms. Terms commonly associated with HF, such as cardiomyopathy and LV dysfunction, are not equivalent to HF but describe possible structural or functional reasons for the development of HF. 

Clinical Presentation and Diagnosis of Acute Heart Failure... 

However, patients with ACS may present with signs of acute heart failure including jugular venous distention and an S3 sound on auscultation. 

The most serious side effects of P-blocker administration early in ACS are hypotension, bradycardia, and heart block. While initial, acute administration of P-blockers is not appropriate for patients who present with decompensated heart failure, initiation of P-blockers maybe attempted before hospital discharge in the majority of patients following treatment of acute heart failure. P-Blockers are continued indefinitely. 

Side effects from /1-blockade in the myocardium include bradycardia, AV conduction abnormalities, and acute heart failure. Blocking / -receptors in arteriolar smooth muscle may cause cold extremities and aggravate PAD or Raynaud s phenomenon because of decreased peripheral blood flow. 

Methanol Inebriation similar to EtOH, metabolic acidosis, tachycardia, HTN, AMS, unresponsive pupils, acute heart failure, cardiac arrhythmias... 

Congestive heart failure (CHF) is a clinical syndrome with multiple causes and involve the right or left ventricle or both and in CHF, cardiac output is usually below the normal range. This ventricular dysfunction may be systolic, which leads to inadequate force generation to eject blood normally and diastolic, which leads to inadequate relaxation to permit normal filling. Systolic dysfunction, with decreased cardiac output and significantly reduced ejection fraction is typical of acute heart failure, especially that resulting from myocardial infarction. 

Severe acute heart failure, hypertensive crisis, controlled hypotension during anaesthesia and severe peri-operative hypertension. 

Isosorbide is available in two forms, isosorbide dinitrate (ISDN) and isosorbide mononitrate (ISDN). ISDN is rapidly metabolised in the liver to the active mononitrate. ISDN is only available in oral form. An intravenous formulation of ISDN is available, but is only used for the treatment of acute heart failure. 

Dobutamine1 Activates adenylyl cyclase, increasing myocardial contractility Positive inotropic effect Cardiogenic shock, acute heart failure IV requires dose titration to desired effect... 

Propranolol Nonselective competitive antagonist at adrenoceptors Decreased heart rate, cardiac output, and blood pressure decreases myocardial oxygen demand Prophylaxis of angina for other applications, see Chapters 10, 11, and 13 Oral and parenteral, 4-6 h duration of action Toxicity Asthma, atrioventricular block, acute heart failure, sedation Interactions Additive with all cardiac depressants... 

Verapamil, diltiazem Nonselective block of L-type calcium channels in vessels and heart Reduced vascular resistance, cardiac rate, and cardiac force results in decreased oxygen demand Prophylaxis of angina, hypertension, others Oral, IV, duration 4-8 h Toxicity Atrioventricular block, acute heart failure constipation, edema Interactions Additive with other cardiac depressants and hypotensive drugs... 

Propranolol 13- Adrenoceptor blockade Direct membrane effects (sodium channel block) and prolongation of action potential duration slows SA node automaticity and AV nodal conduction velocity Atrial arrhythmias and prevention of recurrent infarction and sudden death Oral, parenteral duration 4-6 h Toxicity Asthma, AV blockade, acute heart failure Interactions With other cardiac depressants and hypotensive drugs... 

The toxicity of inamrinone includes nausea and vomiting arrhythmias, thrombocytopenia, and liver enzyme changes have also been reported in a significant number of patients. This drug has been withdrawn in some countries. Milrinone appears less likely to cause bone marrow and liver toxicity than inamrinone, but it does cause arrhythmias. Inamrinone and milrinone are now used only intravenously and only for acute heart failure or severe exacerbation of chronic heart failure. 

Dopamine has also been used in acute heart failure and may be particularly helpful if there is a need to raise blood pressure. 

Vasodilators are effective in acute heart failure because they provide a reduction in preload (through venodilation), or reduction in afterload (through arteriolar dilation), or both. Some evidence suggests that long-term use of hydralazine and isosorbide dinitrate can also reduce damaging remodeling of the heart. 

Acute heart failure occurs frequently in patients with chronic failure. Such episodes are usually associated with increased exertion, emotion, salt in the diet, noncompliance with medical therapy, or increased metabolic demand occasioned by fever, anemia, etc. A particularly common and important cause of acute failure—with or without chronic failure—is acute myocardial infarction. 

Measurements of arterial pressure, cardiac output, stroke work index, and pulmonary capillary wedge pressure are particularly useful in patients with acute myocardial infarction and acute heart failure. Such patients can be usefully characterized on the basis of three hemodynamic measurements arterial pressure, left ventricular filling pressure, and cardiac index. One such classification and therapies that have proved most effective are set forth in Table 13-4. When filling pressure is greater than 15 mm Hg and stroke work index is less than 20 g-m/m2, the mortality rate is high. Intermediate levels of these two variables imply a much better prognosis. 

DeLuca L et al Overview of emerging pharmacologic agents for acute heart failure syndromes. Eur J Heart Failure 2008 10 201. 

Elkayam U et al Vasodilators in the management of acute heart failure. Crit Care Med 2008 36 S95. 

Hill , Yancy CW, Abraham WT Beyond diuretics Management of volume overload in acute heart failure syndromes. Am 3 Med 2006 119 S37. 

A group of nonpeptide antagonists of vasopressin receptors is being investigated for use in patients with hyponatremia or acute heart failure, which is often associated with elevated concentrations of vasopressin. Conivaptan has high affinity for both Vla and V2 receptors. Tolvaptan has a 30-fold higher affinity for V2 than for Vi receptors. In several clinical trials,... 

Gheorghiade M, Teerlink JR, Mebazaa A Pharmacology of new agents for acute heart failure syndromes. Am J Cardiol 2005 96 68G. 

---