Management of Acute Heart Failure

With the aging of the population and improvement in medical care, an increased number of people are surviving an acute myocardial infarction (MI) and subsequently developing heart failure (HF). There also has been an increasing number of hospitalizations for acute heart failure (AHF). A Task Force for AHF Guidelines was formed by the Committee for Practice Guidelines of the European Society of Cardiology. The following is a brief summary of the task force's recommendations for medications used in the management of patients with AHF.¹ The Classes of Recommendations and Levels of Evidence used in these guidelines are comparable to what is commonly used by the American College of Cardiology and the American Heart Association.

Definitions

Classes of Recommendations

• Class I: Evidence or general agreement that a given diagnostic procedure or treatment is beneficial, useful, and effective
• Class II: Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the treatment
  • Class IIa: Weight of evidence/ opinion in favor of usefulness/ efficacy
  • Class IIb: Usefulness/efficacy less well-established by evidence/opinion
• Class III: Evidence or general agreement that the treatment is not useful/ effective and in some cases may be harmful

Levels of Evidence

• A: Data derived from multiple randomized clinical trials or metaanalyses
• B: Data derived from a single randomized clinical trial or large nonrandomized studies
• C: Consensus of opinion of the experts and/or small studies; retrospective studies and registries

Class I Recommendations

• Nitrates: Relieve pulmonary congestion but do not reduce stroke volume or increase myocardial oxygen demand (Level of evidence B)
• Sodium Nitroprusside: Recommended in patients with severe HF with predominantly increased afterload, such as in hypertensive HF (Level of evidence C)
• Diuretics: Should be administered to patients with AHF who have symptoms related to fluid retention (Level of evidence B)
• Life-threatening Arrhythmias: AHF patients in ventricular fibrillation or ventricular tachycardia should be immediately cardioverted. Amiodarone and beta-blockers can help prevent subsequent arrhythmias. (Level of evidence A)

Class IIa Recommendations

• Beta-blockers: Should be initiated early in patients with acute MI who stabilize after developing AHF (Level of evidence C)
• Inotropic Agents: Should be used when there is peripheral hypoperfusion refractory to diuretics and vasodilators at optimal doses (Level of evidence C)
• Dobutamine: Indicated when there is peripheral hypoperfusion refractory to vasodilators and diuretics at optimal doses (Level of evidence C)
• Type III Phosphodiesterase Inhibitors: Preferred to dobutamine in patients taking beta-blockers (Level of evidence C)
• Levosimendan: A drug approved in Europe that is indicated in patients with symptomatic low cardiac output and AHF due to systolic dysfunction without severe hypotension (Level of evidence B)
• Metabolic Support: Using high-dose glucose, insulin, and potassium is not recommended for most patients at this point. (Level of evidence A)
• Management of Bradycardia: It should be treated with atropine and a temporary pacemaker if necessary. (Level of evidence C)
• Control of Ventricular Rate: Important in patients with AHF and atrial fibrillation, especially in patients with diastolic dysfunction (Level of evidence A)

Class IIb Recommendations

• Morphine: Should be used in the early stage of treatment of severe AHF, especially when the patient is experiencing restlessness and dyspnea (Level of evidence B)
• Intravenous (IV) Loop Diuretics: Preferred in patients with AHF. Doses should be titrated for relief of symptoms. (Level of evidence C)
• Beta-blockers: Should be used cautiously in patients with overt AHF and more than basal pulmonary rales. In such patients with ongoing ischemia and tachycardia, however, IV metoprolol may be used. (Level of evidence C)
• Dopamine: May be used as an inotrope (>2 mcg/kg/min) in AHF with hypotension. Low doses of dopamine (2-3 mcg/kg/min) may be used to optimize renal blood flow and diuresis. If no response is observed, however, therapy should be stopped. (Level of evidence C)
• Type III Phosphodiesterase Inhibitors: Indicated when there is peripheral hypoperfusion refractory to optimal doses of vasodilators and diuretics and preserved systemic blood pressure (Level of evidence C)
• Potassium and Magnesium Levels: Should be normalized, especially in patients with ventricular arrhythmia (Level of evidence A)

Other Comments

• Angiotensin-converting Enzyme (ACE) Inhibitors: IV ACE inhibitors should be avoided in AHF, but longterm use of oral ACE inhibitors has been associated with reduction in mortality in HF patients
• Verapamil and Diltiazem: Should be avoided in AHF because they may worsen HF and result in third-degree atrioventricular block
• Anticoagulation: Evidence is lacking regarding the benefit of anticoagulation in AHF
• Vasodilators: Typically first-line therapy if signs and symptoms of hypoperfusion are accompanied by adequate blood pressure and signs of pulmonary congestion with low diuresis
• Diuretic Resistance: May be managed in a number of ways:
  • Restricting sodium and water intake
  • Replacing volume if necessary
  • Using IV diuretics
  • Increasing the dose or frequency of administration of diuretics
  • Combining therapy with thiazides, spironolactone, dopamine, or dobutamine
  • Reducing the dose of an ACE in-hibitor
  • Ultrafiltration or dialysis if response is suboptimal to above strategies
• Dobutamine: Should be used to increase cardiac output. Doses of dobutamine often need to be increased in the presence of betablockers. Effects of dobutamine are additive with phosphodiesterase inhibitors. Dobutamine also is associated with increased risk of arrhythmia.
• Cardiac Glycosides: Should generally not be used in AHF, especially following MI, because they have been associated with a possible increase in life-threatening proarrhythmic events. They may be useful in AHF, however, for tachycardia when other agents, such as betablockers, have proven ineffective.
• Nesiritide: Because it is not currently available on some European markets, nesiritide was not integrated into these recommendations. The guidelines comment, however, on its mechanism of action, dosing, and main side effect of hypotension. Nesiritide has not been shown to have a mortality benefit over other management strategies.

Dr. Tafreshi is an associate professor of pharmacy and medicine and director of the Cardiology Pharmacy Practice Residency at Midwestern University, College of Pharmacy—Glendale (MWU-CPG), Glendale, Ariz. At the time of the completion of this article, Dr. Irving was a senior pharmacy student at MWU-CPG. Dr. Ng is a clinical pharmacist at Banner Estrella Medical Center in Phoenix, Ariz.

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