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Clinical Presentation and Management 175
of Acute Heart Failure

potassium secretion can both enhance the diuresis assigned to either stepped pharmacology therapy or
and minimize the degree of potassium wasting, esp ultrafiltration . The stepped pharmacologic care algo-
with a low or low-normal serum potassium on loop rithm included bolus plus high doses of continuous
diuretic therapy alone. When given for diuresis or po- infusion loop diuretic, the addition of metolazone,
tassium-sparing effects, a higher dose (up to 100 mg and selective use of inotrope or vasodilator therapy.
daily) than the usual HF dose may be needed. The primary end point of change in the serum cre-
atinine level and body weight from baseline to 96
• In patients with refractory volume overload, the hours after enrollment was worse in the Ultrafiltra-
addition of a vasodilator (eg, nitroglycerin, nitro- tion arm due to increase in serum creatinine in that
prusside, or nesiritide) as a temporizing measure group in contrast to a fall in mean serum creatinine in
to relieve congestion.
the pharmacologic therapy group,with no significant
difference in weight loss at 96 hours A higher per-
Ultrafiltration centage of patients in the ultrafiltration group had se-
Ultrafiltration is an effective method of fluid removal rious adverse events (eg, HF, renal failure, anemia or
that provides adjustable fluid removal volumes and thrombocytopenia, electrolyte disorder, hemorrhage,
rates and no effect on serum electrolytes,but is re- pneumonia, sepsis; 72 versus 57 percent).
served for patients with fluid overload who do not
achieve an adequate response to an aggressive di- TREATMENT OF REFRACTORY ACUTE
uretic regimen. This recommendation is consistent HEART FAILURE AND HYPOTENSION
with the 2013 ACC/ AHA HF guidelines. Consulta-
tion with a kidney specialist may be appropriate prior Approach to refractory acute heart failure and hypo-
to opting for a mechanical strategy of fluid removal. tension — The approach to refractory acute heart fail-
Most studies have used a peripherally inserted ultra- ure (HF) and hypotension differs for HF with reduced
filtration device that does not require central access, ejection fraction (HFrEF) and HF with preserved ejec-
specialized nursing, or intensive care unit admission , tion fraction (HFpEF).
however the risk of device thrombosis in recent trials Treatment of patients with HFrEF and refractory vol-
have raised questions about its use, in the wake of ume overload unresponsive to diuretic therapy is
no clear clinical benefit. guided by hemodynamics, clinical findings or by right

The efficacy of ultrafiltration in patients with ADHF heart catheterization performed selectively. Intrave-
has been evaluated in several randomized trials : nous vasodilator therapy is suggested for patients
with refractory HF without symptomatic hypotension.
In the UNLOAD trial, 200 patients hospitalized for Selected patients with hypotension may benefit from
ADHF were randomly assigned to ultrafiltration or to vasodilator therapy guided by invasive monitoring,
standard care, including intravenous diuretics found including pulmonary artery catheter. If the systolic
that: blood pressure is <85 mmHg or there is evidence
• At 48 hours, patients assigned to ultrafiltration had of shock , an inotrope is added . In patients with
a significantly greater fluid loss (4.6 versus 3.3 li- persistent shock, a vasopressor may be added as
ters with standard care) and at 90 days, patients a temporizing measure to support perfusion to vital
assigned to ultrafiltration had significantly fewer organs, though this is at the expense of increased
HF rehospitalizations than patients assigned to left ventricular afterload. For selected patients with
standard care (0.22 versus 0.46 admissions per severe HFrEF (generally with left ventricular ejection
patient) and fewer unscheduled clinic visits (21 fraction <25 percent) with acute, severe hemody-
versus 44 percent with standard care). namic compromise, nondurable mechanical support
(eg, intraaortic balloon pump [IABP], extracorporeal
• The rates of adverse events were similar in the two circulatory membrane oxygenator [ECMO], or extra-
groups, although there was a higher incidence of corporeal ventricular assist devices) is an option as
bleeding in the standard care arm. There was no a “bridge to decision” or “bridge to recovery” , espe-
difference in serum creatinine, as was also found cially common in the current era of complex PCI in
in a smaller trial with detailed assessment of renal ACS patients.
hemodynamics .
Patients with HFpEF presenting with hypotension
In CARRESS-HF, 188 patients with ADHF, worsened should not receive inotropes and may require a va-
renal function (defined as an increase in the serum sopressor in addition to diuretic therapy. Patients
creatinine level of at least 0.3 mg/dL [26.5 micro- who develop hypotension with dynamic LV outflow
mol/L]), and persistent congestion were randomly obstruction are treated with beta blocker therapy, a

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