Treatment Options

Acute

Patient Group Tx Line Treatment
hemodynamically stable 1st oxygen therapy

  • High flow oxygen is recommended in patients with a capillary oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa) to correct hypoxemia. [1] [2]
adjunct morphine

  • Opioids such as morphine may be useful as they reduce anxiety and relieve distress associated with dyspnea. [1] [2]Morphine should be considered only in patients who are restless and distressed. Alertness and respiration should be monitored frequently as opioids (such as morphine) can depress respiration, potentially increasing the need for mechanical ventilation.
  • Primary Options
plus loop diuretic

  • Indicated in patients with evidence of pulmonary congestion and volume overload. [1] [2]Loop diuretics used for the treatment of acute heart failure and congestion include furosemide, bumetanide, and torsemide. The most commonly used agent appears to be furosemide, but some patients may respond more favorably to another loop diuretic (e.g. bumetanide, torsemide). Initially on hospitalization an intravenous agent (bolus or continuous infusion) is usually employed.The minimum dose of diuretics should be used to relieve congestion, keep the patient asymptomatic, and maintain a dry weight.
  • Primary Options
    • furosemide: 40-160 mg/dose orally/intravenously initially, increase by 20-40 mg/dose every 6-12 hours according to response, maximum 600 mg/day
    • bumetanide: 0.5 to 2 mg orally/intravenously once or twice daily initially, increase dose according to response, maximum 10 mg/day
    • torsemide: 10-20 mg orally/intravenously once daily initially, increase dose according to response, maximum 200 mg/day
plus vasodilators

  • Indicated in patients with pulmonary congestion/edema and a systolic BP >90 mmHg. [53] [59]Both IV nitroglycerin and nesiritide lower left ventricular filling pressure and provide symptomatic improvement. [81]Nitroglycerin is the preferred agent with nesiritide considered less preferred, as there is some concern about worsening in renal function with nesiritide and increased mortality. [54] [82] [83]

    However, a retrospective observational analysis from the ADHERE study showed that both nesiritide and nitroglycerin are equally safe in the treatment of acute CHF. [13]

  • Primary Options
    • nitroglycerin: 5 micrograms/min intravenously initially, increase by 5-20 micrograms/min increments every 3-5 minutes according to response, maximum 200 micrograms/min
  • Secondary Options
    • nesiritide: 2 micrograms/kg/dose intravenous bolus initially, followed by 0.01 micrograms/kg/min infusion
plus supportive care

  • Continued supportive care includes maintenance of adequate oxygenation, patent airways, a low salt diet, and restriction of daily fluid intake.
adjunct ventilation

  • Required if oxygen saturation cannot be maintained with oxygenation alone. [48]Noninvasive positive pressure ventilation (NIPPV) or CPAP should be tried first. Mechanical ventilation is only used when other treatments, including NIPPV, fail.
inadequate response to loop diuretics adjunct nonloop diuretic

  • Indicated in patients with evidence of pulmonary congestion and volume overload. [1] [2]Nonloop diuretics are commonly used in combination with loop diuretics to improve diuresis. In resistant cases, a loop diuretic should be combined with a thiazide-like diuretic (e.g. metolazone). Careful monitoring of renal function and electrolytes is essential in these patients.The minimum dose of diuretics should be used to relieve congestion, keep the patient asymptomatic, and maintain a dry weight.
  • Primary Options
due to cardiac ischemia plus aspirin ± revascularization

  • Aspirin is given to all patients (in the absence of contraindication) with coronary ischemia and those undergoing revascularization.Revascularization may be achieved with percutaneous revascularization or, in selected cases, with coronary artery bypass grafting.
  • Primary Options
    • aspirin: 165-325 mg orally as a single dose, followed by 75-100 mg once daily thereafter
due to valvular disease adjunct nitroprusside

  • Indicated in patients with aortic stenosis, aortic regurgitation, mitral stenosis, or mitral regurgitation who are not hypotensive.Dose of nitroprusside exceeding 400 micrograms/minute generally does not produce added benefit and may increase the risk of thiocyanate toxicity. [84]
  • Primary Options
    • nitroprusside: 0.3 micrograms/kg/min intravenously initially, increase by 0.5 micrograms/kg/min increments according to response, usual dose is 5 micrograms/kg/min
due to acute right heart failure plus treatment of underlying cause

  • Therapy is centered around treatment of the underlying pathology; e.g., pulmonary embolism (anticoagulation, thrombolytics, catheterization, or surgically directed thrombectomy), right ventricular infarction (PCI or thrombolytics), and chronic thromboembolic pulmonary hypertension (thromboendarterectomy). [68]
due to acute myocarditis plus supportive care or immunosuppressant therapy

  • Giant cell myocarditis is treated with single or combination immunosuppressant therapy including corticosteroids, azathioprine, cyclosporine, and muromonab-CD3 (OKT3). [69]Treatment of other forms of myocarditis is limited to supportive care. [70]
inadequate response to combination diuretics adjunct ultrafiltration

  • For patients with volume overload who do not respond to medical therapy.
hypotensive (systolic BP <90 mmHg) 1st oxygen therapy

  • High flow oxygen is recommended in patients with a capillary oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa) to correct hypoxemia. [1] [2]
plus inotrope and/or vasopressor

  • Patients with hypotension (systolic BP <90 mmHg) or shock should be commenced on an inotrope and/or vasopressor. [1] [2]Positive inotropes should be used with caution because there is evidence that they result in increased mortality, and can cause arrhythmias and worsening of coronary ischemia. [13] [85] 3[B] Evidence Evidence 6[B] Evidence EvidenceThe infusion rate is modified according to symptoms, diuretic response, or hemodynamic monitoring.

    Choice of inotrope depends on clinical findings.

    Dobutamine or milrinone are recommended for patients with systolic BP 85 to 100 mmHg. [48]

    Dopamine and/or norepinephrine are recommended for patients with systolic BP <85 mmHg. [48]

    Inotropes are not recommended unless the patient is hypotensive (i.e., systolic BP <90 mmHg), hypoperfused, or in shock. [1] [2]

    In general, a vasopressor (e.g., dopamine or norepinephrine) should be considered in patients who do not improve despite treatment with an inotrope (e.g., dobutamine). Both inotropes and vasopressors cause tachycardia and may induce myocardial ischemia and arrhythmias.

  • Primary Options
    • milrinone: 25-50 micrograms/kg/dose intravenously over 10-20 minutes, followed by 0.375 to 0.75 micrograms/kg/min infusion
    • dobutamine: 2-20 micrograms/kg/min intravenously
    • dopamine : 5-15 micrograms/kg/min intravenously

      and/or

    • norepinephrine: 0.5 to 30 micrograms/min intravenously
plus supportive care

  • Continued supportive care includes maintenance of adequate oxygenation, patent airways, a low salt diet, and restriction of daily fluid intake.
adjunct ventilation

  • Required if oxygen saturation cannot be maintained with oxygenation alone. [48]Noninvasive positive pressure ventilation (NIPPV) or CPAP should be tried first. Mechanical ventilation is only used when other treatments including NIPPV fail.
2nd intra-aortic balloon pump

  • Required in patients with persistent cardiogenic shock despite inotropic therapy.
3rd left ventricular assist device (LVAD)

  • The use of LVADs has evolved significantly over the past 25 years and various types of LVAD now exist. [71] Extracorporeal devices, the most common of which are the extracorporeal membrane oxygenators (ECMOs), require full heparinization and are typically used for days or weeks as a bridge for patients who are expected to recover within days. Percutaneous short-term devices (e.g., Tandem Heart) are inserted through the femoral artery and advanced into the left ventricle. Longer-term assist devices are divided into first-generation (e.g., Heart Mate I), second-generation (e.g., Heart Mate II), and third-generation (e.g., HVAD and Dura Heart) devices. The third-generation pumps are thought to last as long as 5 to 10 years and are currently being evaluated in several phase 1 studies. [73]
due to cardiac ischemia plus aspirin ± revascularization

  • Aspirin is given to all patients (in the absence of contraindication) with coronary ischemia and those undergoing revascularization.Revascularization may be achieved with percutaneous revascularization or, as second-line therapy, coronary artery bypass.
  • Primary Options
    • aspirin: 165-325 mg orally as a single dose, followed by 75-100 mg once daily thereafter
due to valve stenosis adjunct percutaneous valvotomy

  • Used as a bridge to aortic valve replacement. May be considered for mitral stenosis if no thrombus present on transesophageal echocardiogram.
hypertensive crisis 1st oxygen therapy

  • High flow oxygen is recommended in patients with a capillary oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa) to correct hypoxemia. [1] [2]
plus intravenous beta-blocker and nitroglycerin

  • Use of an intravenous beta-blocker and nitroglycerin is recommended. If additional medications are needed, nitroprusside is recommended in addition to other choices.
  • Primary Options
    • metoprolol tartrate : 5-10 mg intravenously every 4-6 hours

      or

    • esmolol: 250-500 micrograms/kg/dose intravenously over 1 minute initially, followed by 50-100 micrograms/kg/min infusion for 4 minutes, may repeat loading dose and increase infusion up to 200 micrograms/kg/min according to response, consult specialist for further guidance on dose
    • — AND —
    • nitroglycerin: 5 micrograms/min intravenously initially, increase by 5-20 micrograms/min increments every 3-5 minutes according to response, maximum 200 micrograms/min
adjunct nitroprusside

  • Dose of nitroprusside exceeding 400 micrograms/minute generally does not produce added benefit and may increase the risk of thiocyanate toxicity. [84]
  • Primary Options
    • nitroprusside: 0.3 micrograms/kg/min intravenously initially, increase by 0.5 micrograms/kg/min increments according to response, usual dose is 5 micrograms/kg/min
plus supportive care

  • Continued supportive care includes maintenance of adequate oxygenation, patent airways, a low salt diet, and restriction of daily fluid intake.Precipitating factors such as pain and agitation should be also be controlled.
adjunct ventilation

  • Required if oxygen saturation cannot be maintained with oxygenation alone. [48]Noninvasive positive pressure ventilation (NIPPV) or CPAP should be tried first. Mechanical ventilation is only used when other treatments including NIPPV fail.

Ongoing

Patient Group Tx Line Treatment
acute episode stabilized: LVEF <50% and systolic BP >100 mmHg 1st ACE inhibitor or angiotensin-II receptor antagonist or sacubitril/valsartan

  • An ACE inhibitor is the preferred agent. An angiotensin-II receptor antagonist is only used in patients who are intolerant of ACE inhibitors. [31] A combination of an ACE inhibitor and angiotensin-II receptor antagonist should be avoided because of the risk of renal dysfunction and hyperkalemia.The combination of sacubitril, a neprilysin inhibitor, and valsartan, an angiotensin-­II receptor antagonist, is recommended as a replacement for an ACE inhibitor in patients with reduced ejection fraction (NYHA class II, III, IV and LVEF ≤35%) and who remain symptomatic despite optimal treatment with an ACE inhibitor, a beta­-blocker, and a mineralocorticoid receptor antagonist. [1] [74]Dose should be started low and increased according to response. Treatment is targeted to maximum dose tolerated.
  • Primary Options
    • captopril: 6.25 to 50 mg orally three times daily
    • ramipril: 1.25 to 10 mg orally once daily
  • Secondary Options
    • sacubitril/valsartan : 49 mg (sacubitril)/51 mg (valsartan) orally twice daily initially, increase gradually according to response, maximum 97 mg (sacubitril)/103 mg (valsartan) more

      Allow 36 hours between stopping an ACE inhibitor and starting this drug.

      A lower dose may be used in patients previously on a low dose of an ACE inhibitor or angiotensin-II receptor antagonist.

plus beta-blocker

  • The pivotal trials with beta-blockers were conducted in patients with continuing symptoms and a persistently low EF, despite treatment with an ACE inhibitor and, in most cases, a diuretic. Despite this, there is consensus that these treatments are complementary and that a beta-blocker and an ACE inhibitor should both be started as soon as possible after diagnosis of heart failure with reduced ejection fraction (HF-REF). [1] [2]Typically, beta-blockers are started only after the patient has been stabilized and is in compensated heart failure.Treatment is targeted to maximum dose tolerated.
  • Primary Options
    • bisoprolol: 1.25 mg orally once daily initially, increase according to response, maximum 10 mg/day
    • carvedilol: 3.125 mg orally (immediate-release) twice daily initially, increase according to response, maximum 50 mg/day
    • nebivolol: 1.25 mg orally once daily initially, increase according to response, maximum 10 mg/day
plus aldosterone receptor antagonist

  • Spironolactone and eplerenone block receptors that bind aldosterone and other corticosteroids.These agents can cause hyperkalemia and worsening renal function, especially in older people. Both should only be used in patients with adequate renal function and a normal serum potassium concentration.Serial monitoring of serum electrolytes and renal function are mandatory.
  • Primary Options
    • eplerenone: 25 mg orally once daily initially, increase according to response, maximum 50 mg/day
    • spironolactone: 25 mg orally once daily initially, increase according to response, maximum 50 mg/day
adjunct vasodilators

  • Isosorbide dinitrate/hydralazine can be used as a second line treatment in addition to ACE inhibitors or angiotensin-II receptor antagonists. It can also be used as an alternative to ACE inhibitors if these are contraindicated. Black people, in particular, have been shown to gain benefit from this combination of drugs.
  • Primary Options
    • isosorbide dinitrate/hydralazine: 20 mg (isosorbide dinitrate)/37.5 mg (hydralazine) orally three times daily initially, increase according to response, maximum 40 mg(isosorbide dinitrate)/75 mg (hydralazine) three times daily
adjunct loop diuretic ± nonloop diuretic

  • Patients who have evidence of volume overload or pulmonary congestion are continued on loop diuretics.Most patients with decreased LV function will need long-term diuretics, whereas those with primary diastolic heart failure will usually not need to be kept on maintenance diuretics.Diuretics should be used only in combination with an ACE inhibitor (or an angiotensin-II receptor antagonist), a beta-blocker, and an aldosterone antagonist in patients with reduced left ventricular ejection fraction.

    Loop diuretics used for the treatment of acute heart failure and congestion include furosemide, bumetanide, and torsemide. The most commonly used agent appears to be furosemide, but some patients may respond more favorably to another loop diuretic (e.g. bumetanide, torsemide). In resistant cases loop diuretics should be combined with a thiazide-like diuretic (e.g. metolazone). Careful monitoring of renal function and electrolytes is essential in these patients.

    The minimum dose of diuretics should be used to relieve congestion, keep the patient asymptomatic, and maintain a dry weight. In patients with stable congestive heart failure, loop diuretics are the preferred agent. In patients with hypertension and only mild fluid retention, a thiazide diuretic may be considered, but almost all patients with acute heart failure will need loop diuretics.

  • Primary Options
    • furosemide: 40-160 mg/dose orally/intravenously initially, increase by 20-40 mg/dose every 6-12 hours according to response, maximum 600 mg/day
    • bumetanide: 0.5 to 2 mg orally/intravenously once or twice daily initially, increase dose according to response, maximum 10 mg/day
    • torsemide: 10-20 mg orally/intravenously once daily initially, increase dose according to response, maximum 200 mg/day
    • furosemide : 40-160 mg/dose orally/intravenously initially, increase by 20-40 mg/dose every 6-12 hours according to response, maximum 600 mg/day

      or

    • bumetanide : 0.5 to 2 mg orally/intravenously once or twice daily initially, increase dose according to response, maximum 10 mg/day

      or

    • torsemide: 10-20 mg orally/intravenously once daily initially, increase dose according to response, maximum 200 mg/day
    • — AND —
    • metolazone: 2.5 to 10 mg orally once daily
adjunct digoxin

  • Digoxin significantly reduces the risk of composite end point of mortality or hospitalization in ambulatory chronic heart failure patients with NYHA class 3 or 4 symptoms, LVEF <25%, or cardiothoracic ratio of >55%, and should be considered in these patients. [79]In patients with heart failure who are in sinus rhythm, use of digoxin has no effect on mortality but is associated with a lower rate of hospitalization and clinical deterioration. [80]
  • Primary Options
    • digoxin: consult specialist for guidance on dose
adjunct ivabradine

  • Treatment with ivabradine in stable patients with chronic heart failure (i.e., LVEF <35%) and a resting heart rate of >70 bpm – on a background of guideline-based heart failure therapy – is associated with reducing the risk of hospitalization for worsening heart failure. [31] [77] In a randomized, double-blind, placebo-controlled trial, addition of ivabradine to standard background therapy did not improve the outcome in patients with stable coronary artery disease without clinical heart failure (no evidence of left ventricular systolic dysfunction, in the overall study population mean ejection fraction was 56.4%). In the subgroup analysis of the study, ivabradine was associated with an increase in the incidence of the primary end point (death from cardiovascular causes or nonfatal myocardial infarction) among patients who had angina of Canadian Cardiovascular Society (CCS) class II or higher but not among patients without angina or those who had angina of class I. Ivabradine was associated with an increased incidence of bradycardia, QT prolongation, and atrial fibrillation. [78]
  • Primary Options
    • ivabradine: 5 mg orally twice daily initially, may increase to 7.5 mg twice daily after 2 weeks if necessary
plus supportive care

  • Continued supportive care includes maintenance of adequate oxygenation (ideally maintained between 95% and 98% to maximize tissue oxygenation), patent airways, a low salt diet, and restriction of daily fluid intake.
acute episode stabilized: LVEF <50% and systolic BP 90-100 mmHg 1st ACE inhibitor or angiotensin-II receptor antagonist or sacubitril/valsartan

  • Patients with a systolic BP <100 mmHg are generally not able to tolerate vasodilators or beta-blockers. However, in clinical practice hospitalized patients with a systolic BP >90 mmHg and no symptoms of hypotension can be started on the minimum starting dose of an ACE inhibitor with close blood pressure monitoring. An angiotensin-II receptor antagonist is only used in patients who are intolerant of ACE inhibitors. [31]A combination of sacubitril, a neprilysin inhibitor, and valsartan, an angiotensin-II receptor antagonist, is recommended for patients with reduced ejection fraction (NYHA class II, III, IV and LVEF ≤35%) and who remain symptomatic despite treatment with an ACE inhibitor, a beta­-blocker, and a mineralocorticoid receptor antagonist. [1] [74]A beta-blocker can be used if ACE inhibitors are contraindicated or not tolerated.
  • Primary Options
    • captopril: 6.25 to 12.5 mg orally three times daily initially, increase according to response, maximum 450 mg/day
    • lisinopril: 2.5 to 5 mg orally once daily initially, increase according to response, maximum 40 mg/day
    • ramipril: 1.25 mg orally once daily initially, increase according to response, maximum 10 mg/day
    • enalapril: 2.5 mg orally once daily initially, increase according to response, maximum 40 mg/day
  • Secondary Options
    • sacubitril/valsartan : 49 mg (sacubitril)/51 mg (valsartan) orally twice daily initially, increase gradually according to response, maximum 97 mg (sacubitril)/103 mg (valsartan) more

      Allow 36 hours between stopping an ACE inhibitor and starting this drug.

      A lower dose may be used in patients previously on a low dose of an ACE inhibitor or angiotensin-II receptor antagonist.

adjunct beta-blocker

  • Patients with a systolic BP <100 mmHg are generally not able to tolerate beta-blockers or vasodilators. However, if BP improves on an ACE inhibitor and the patient is able to tolerate it, then a beta-blocker can be introduced at a low dose and cautiously titrated upward.If ACE inhibitors are contraindicated or not tolerated, beta-blockers can also be used first line.
  • Primary Options
    • bisoprolol: 1.25 mg orally once daily initially, increase according to response, maximum 10 mg/day
    • carvedilol: 3.125 mg orally (immediate-release) twice daily initially, increase according to response, maximum 50 mg/day
    • nebivolol: 1.25 mg orally once daily initially, increase according to response, maximum 10 mg/day
adjunct aldosterone receptor antagonist

  • Spironolactone and eplerenone block receptors that bind aldosterone and other corticosteroids.These agents can cause hyperkalemia and worsening renal function, especially in older people. Both should only be used in patients with adequate renal function and a normal serum potassium concentration.Serial monitoring of serum electrolytes and renal function are mandatory.
  • Primary Options
    • eplerenone: 25 mg orally once daily initially, increase according to response, maximum 50 mg/day
    • spironolactone: 25 mg orally once daily initially, increase according to response, maximum 50 mg/day
adjunct vasodilators

  • Isosorbide dinitrate/hydralazine can be used as a second line treatment in addition to ACE inhibitors or beta-blockers. It can also be used as an alternative to ACE inhibitors if these are contraindicated. Black people, in particular, have been shown to gain benefit from this combination of drugs.
  • Primary Options
    • isosorbide dinitrate/hydralazine: 20 mg (isosorbide dinitrate)/37.5 mg (hydralazine) orally three times daily initially, increase according to response, maximum 40 mg(isosorbide dinitrate)/75 mg (hydralazine) three times daily
adjunct loop diuretic ± nonloop diuretic

  • Most patients require diuretics, depending upon volume status and left ventricular systolic function.Patients who have evidence of volume overload or pulmonary congestion are continued on loop diuretics.Most patients with decreased LV function will need long-term diuretics, whereas those with primary diastolic heart failure will usually not need to be kept on maintenance diuretics.

    Loop diuretics used for the treatment of acute heart failure and congestion include furosemide, bumetanide, and torsemide. The most commonly used agent appears to be furosemide, but some patients may respond more favorably to another loop diuretic (e.g. bumetanide, torsemide). In resistant cases loop diuretics should be combined with a thiazide-like diuretic (e.g. metolazone). Careful monitoring of renal function and electrolytes is essential in these patients.

    Diuretics should be started at the minimum starting dose with close blood pressure monitoring. The minimum dose of diuretics should be used to relieve congestion, keep the patient asymptomatic, and maintain a dry weight. In patients with stable congestive heart failure, loop diuretics are the preferred agent. In patients with hypertension and only mild fluid retention, a thiazide diuretic may be considered, but almost all patients with acute heart failure will need loop diuretics.

  • Primary Options
    • furosemide: 40-160 mg/dose orally/intravenously initially, increase by 20-40 mg/dose every 6-12 hours according to response, maximum 600 mg/day
    • bumetanide: 0.5 to 2 mg orally/intravenously once or twice daily initially, increase dose according to response, maximum 10 mg/day
    • torsemide: 10-20 mg orally/intravenously once daily initially, increase dose according to response, maximum 200 mg/day
    • furosemide : 40-160 mg/dose orally/intravenously initially, increase by 20-40 mg/dose every 6-12 hours according to response, maximum 600 mg/day

      or

    • bumetanide : 0.5 to 2 mg orally/intravenously once or twice daily initially, increase dose according to response, maximum 10 mg/day

      or

    • torsemide: 10-20 mg orally/intravenously once daily initially, increase dose according to response, maximum 200 mg/day
    • — AND —
    • metolazone: 2.5 to 10 mg orally once daily
adjunct digoxin

  • Digoxin significantly reduces the risk of composite end point of mortality or hospitalization in ambulatory chronic heart failure patients with NYHA class 3 or 4 symptoms, LVEF <25%, or cardiothoracic ratio of >55%, and should be considered in these patients. [79]In patients with heart failure who are in sinus rhythm, use of digoxin has no effect on mortality but is associated with a lower rate of hospitalization and clinical deterioration. [80]
  • Primary Options
    • digoxin: consult specialist for guidance on dose
adjunct ivabradine

  • Treatment with ivabradine in stable patients with chronic heart failure (i.e., LVEF <35%) and a resting heart rate of >70 bpm – on a background of guideline-based heart failure therapy – is associated with reducing the risk of hospitalization for worsening heart failure. [77] In a randomized, double-blind, placebo-controlled trial, addition of ivabradine to standard background therapy did not improve the outcome in patients with stable coronary artery disease without clinical heart failure (no evidence of left ventricular systolic dysfunction, in the overall study population mean ejection fraction was 56.4%). In the subgroup analysis of the study, ivabradine was associated with an increase in the incidence of the primary end point (death from cardiovascular causes or nonfatal myocardial infarction) among patients who had angina of Canadian Cardiovascular Society (CCS) class II or higher but not among patients without angina or those who had angina of class I. Ivabradine was associated with an increased incidence of bradycardia, QT prolongation, and atrial fibrillation. [78]
  • Primary Options
    • ivabradine: 5 mg orally twice daily initially, may increase to 7.5 mg twice daily after 2 weeks if necessary
plus supportive care

  • Continued supportive care includes maintenance of adequate oxygenation (ideally maintained between 95% and 98% to maximize tissue oxygenation), patent airways, a low salt diet, and restriction of daily fluid intake.
acute episode stabilized: LVEF ≥50% 1st ACE inhibitor or beta-blocker

  • For patients with normal or preserved EF (diastolic heart failure), good control of blood pressure, arrhythmias, and underlying ischemia are essential. No treatment has been convincingly shown to reduce mortality in this subset of patients.An ACE inhibitor is the first line choice for patients with hypertension in this category of patient. A beta-blocker is the first line choice for patients with ischemia or arrhythmia.
  • Primary Options
    • captopril: 6.25 to 12.5 mg orally three times daily initially, increase according to response, maximum 450 mg/day
    • lisinopril: 2.5 to 5 mg orally once daily initially, increase according to response, maximum 40 mg/day
    • ramipril: 1.25 mg orally once daily initially, increase according to response, maximum 10 mg/day
    • enalapril: 2.5 mg orally once daily initially, increase according to response, maximum 40 mg/day
    • bisoprolol: 1.25 mg orally once daily initially, increase according to response, maximum 10 mg/day
    • carvedilol: 3.125 mg orally (immediate-release) twice daily initially, increase according to response, maximum 50 mg/day
    • nebivolol: 1.25 mg orally once daily initially, increase according to response, maximum 10 mg/day
adjunct loop diuretic ± nonloop diuretic

  • The aim of using diuretics is to achieve and maintain euvolemia (the patient’s ‘dry weight’) with the lowest achievable dose. Once ‘dry’ body weight is achieved, reduction in diuretic dose is often required to avoid dehydration, hypotension, and renal dysfunction. Some patients can be trained to self-adjust their diuretic dose based on monitoring of symptoms and signs of congestion as well as daily weight measurements. [1] [2]Patients with primary diastolic heart failure (i.e., HF with ‘preserved’ EF) will usually not need to be kept on maintenance diuretics.Loop diuretics used for the treatment of acute heart failure and congestion include furosemide, bumetanide, and torsemide. The most commonly used agent appears to be furosemide, but some patients may respond more favorably to another loop diuretic (e.g. bumetanide, torsemide). In resistant cases loop diuretics should be combined with a thiazide-like diuretic (e.g. metalozone). Careful monitoring of renal function and electrolytes is essential in these patients.

    Diuretics should be started at the minimum starting dose with close blood pressure monitoring. The minimum dose of diuretics should be used to relieve congestion, keep the patient asymptomatic, and maintain a dry weight. In patients with stable congestive heart failure, loop diuretics are the preferred agent. In patients with hypertension and only mild fluid retention, a thiazide diuretic may be considered, but almost all patients with acute heart failure will need loop diuretics

  • Primary Options
    • furosemide: 40-160 mg/dose orally/intravenously initially, increase by 20-40 mg/dose every 6-12 hours according to response, maximum 600 mg/day
    • bumetanide: 0.5 to 2 mg orally/intravenously once or twice daily initially, increase dose according to response, maximum 10 mg/day
    • torsemide: 10-20 mg orally/intravenously once daily initially, increase dose according to response, maximum 200 mg/day
    • furosemide : 40-160 mg/dose orally/intravenously initially, increase by 20-40 mg/dose every 6-12 hours according to response, maximum 600 mg/day

      or

    • bumetanide : 0.5 to 2 mg orally/intravenously once or twice daily initially, increase dose according to response, maximum 10 mg/day

      or

    • torsemide: 10-20 mg orally/intravenously once daily initially, increase dose according to response, maximum 200 mg/day
    • — AND —
    • metolazone: 2.5 to 10 mg orally once daily
plus supportive care

  • Continued supportive care includes maintenance of adequate oxygenation (ideally maintained between 95% and 98% to maximize tissue oxygenation), patent airways, a low salt diet, and restriction of daily fluid intake.

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