Management of Heart Failure By MOH

Posted by:Dr.Zharif




Investigation

Blood test – FBC, renal function, liver function, glucose, lipid profile

urinalysis – proteinuria, glycosuria

Other important investigations include: • echocardiogram – to identify structural abnormalities and assess LV systolic and diastolic dysfunction

natriuretic peptides or their precursors (especially BNP and NT-proBNP) – If available, this investigation is useful in the evaluation of patients presenting IIa.A with acute dyspnoea in the urgent care setting in whom the clinical diagnosis of HF is uncertain. A low-normal concentration of this marker in an untreated patient makes the diagnosis of HF unlikely.Thus it is a useful “rule–out” test in doubtful cases.

Additional investigations when indicated;

Blood tests:

– cardiac biomarkers – thyroid function tests

– C-reactive protein (to look for inflammation)

Tests for myocardial ischemia and/or viability: – treadmill exercise test

– stress echocardiography (exercise or pharmacological)

– radionuclide studies

– cardiac magnetic resonance imaging (CMR)

Invasive tests:

– coronary angiography – cardiac catheterization – endomyocardial biopsy

Others:

– Holter electrocardiography, loop recorders and long-time ECG recording – pulmonary function tests


Management

The principles of management are:

Rapid recognition of the condition

Stabilization of hemodynamics

Improvement in clinical symptoms and signs

Identification and treatment of the

– underlying cause

– precipitating / aggravating factors.

The initial management includes a combination of the following first line therapy:

Oxygen – 5 to 6 liters/minute, by mask with the aim of achieving oxygen saturation of more than 95% in order to maximize tissue oxygenation and to prevent end organ dysfunction or multi organ failure. Elective ventilation using non invasive positive pressure ventilation (Continuous Positive Airway Pressure [CPAP] or Bi-level Positive Airway Pressure [BiPAP])should be considered early if necessary Should the oxygen saturation be inadequate or the patient develop respiratory muscle fatigue, then endotracheal intubation and mechanical ventilation is necessary.

Frusemide – Intravenous (i.v.) frusemide 40 – 100mg. The dose should be

individualized depending on the severity of the clinical condition

Administration of a loading dose followed by a continuous infusion has been

shown to be more effective than repeated bolus injections alone .The

dose should be titrated according to clinical response and renal function.

Morphine sulphate – i.v. 3 – 5 mg bolus (repeated if necessary, up to a total maximum of 10mg). It reduces pulmonary venous congestion and sympathetic drive. It is most useful in patients who are dyspnoeic and restless. Intravenous anti-emetics (metoclopramide 10mg or prochlorperazine 12.5mg) should be administered concomitantly. Care must be exercised in patients with chronic respiratory diseases.

Nitrates - If the BP is adequate (SBP > 100 mmHg), nitrates are indicated as first line therapy in AHF. It should be administered sublingually or intravenously. The i.v. route is more effective and preferable. Patients should be closely monitored for hypotension. This commonly occurs with concomitant diuretic therapy. Studies have shown that the combination of i.v. nitrate and low dose frusemide is more efficacious than high dose diuretic treatment alone .

Extreme caution should be exercised in patients with aortic and mitral stenosis.

Nitrates are contraindicated in severe valvular stenosis

	Route of	Dosages
	Admin
Diuretics
Frusemide	IV	40mg – 100mg
	Infusion	5 – 40mg/hour (better than very high bolus
		doses)
Vasodilators
Nitroglycerin	Infusion	5ug/min increasing at intervals of 3 – 5 min
		by 5ug/min increments up to 100 – 200
		ug/min
Nitroprusside	Infusion	0.1 – 5ug/kg/min
Sympathomimetics
Dobutamine	Infusion	2 – 20ug/kg/min
Dopamine	Infusion	<2>
		2 – 10ug/kg/min – inotropic doses
		10 – 20ug/kg/min –
		peripheral vasoconstriction
Noradrenaline	Infusion	0.02 – 1ug/kg/min till desired BP is
		attained
Phosphodiesterase-
3- Inhibitors
Milrinone	Infusion	50ug/kg bolus then 0.375 – 0.75ug/kg/min

Grading of Recommendations of Therapies in the Management of AHF

Intervention	Grades of	Level of
	Recommen-		Comments
		Evidence
	dation
	INITIAL MANAGEMENT CONSISTS OF :
			Maintain the oxygen saturation above
Oxygen	I	C
			95%
Diuretics	I	B	Indicated for fluid retention
Nitrates	I	B	Contraindicated if SBP<>
			with caution in valvular stenosis.
Morphine	IIb	C	Indicated in pts who are dyspnoeic and
			restless
NOT RESPONSIVE TO INITIAL TREATMENT AND SBP≥100mmHg
			continuous infusion; combination with
Diuretics	IIb	C	nitrates, dopamine, dobutamine or
			thiazide
Dobutamine	IIa	C	Indicated for peripheral hypoperfusion +/-
			pulmonary congestion
Dopamine	IIb	C	To improve renal perfusion and promote
(<2>µg/kg/min)			diuresis
Milrinone	IIb	C	Improves symptoms and hemodynamics.
Sodium	I	C	Indicated in hypertensive crisis and acute
Nitroprusside			valvular regurgitation
NOT RESPONSIVE TO INITIAL TREATMENT AND SBP<100mmhg
			Indicated to increase the BP
Dopamine	IIa	C
(>2µg/kg/min)
Noradrenaline	IIb	C	Indicated to increase the BP
			Indicated as a bridge till myocardial
IABP	I	B	recovery or heart transplant
Ventricular			Indicated as a bridge till myocardial
Assist Device
	IIa	B	recovery or heart transplant
(VAD)

For more detail Information about Management of Heart Failure By MOH
u can download the pdf file HERE