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178 Cardio Diabetes Medicine 2017

put directly. Instead, arterial blood is drawn from a tion.
peripheral artery and recirculated through the aorta Major concerns with early therapy include:Patients
via an extracorporeal pump that then returns blood with ADHF may develop hypotension and/or wors-
through a second arterial access site. Increased aor- ening renal function during initial therapy. Early initi-
tic flow is postulated to stimulate favorable hemody- ation of oral ACE inhibitor may be deletirious in pa-
namic changes, primarily through cardiac unloading tients at high risk for hypotension (eg, low baseline
and peripheral vasodilation.
blood pressure or hyponatremia).Aggressive diuretic
In the MOMENTUM trial, 168 patients hospitalized therapy typically given for acute pulmonary edema
with HF with reduced LVEF were randomly assigned may increase sensitivity to ACE inhibition or angio-
to CAFA plus medical therapy or medical therapy tensin blockade, including risks of hypotension and
alone . The primary composite efficacy end point renal dysfunction.
included PCWP and days alive out of hospital off Ivabradine — Ivabradine reduces the risk of hospital-
mechanical support over 35 days and was similar in ization in patients with chronic HFrEF esp with betbut
the two treatment groups. CAFA improved cardiac in- has no proven role in acute HF.
dex, cardiac performance and PCWP;however major
bleeds occurred in 16.5 percent in the device group Mineralocorticoid receptor antagonist(MRA) —MRA
and 5.1 percent in the control group. therapy (spironolactone or eplerenone) reduces mor-
tality when included in long-term management of se-
CONTINUATION OR INITIATION OF LONG- lected patients with systolic HF who can be carefully
TERM THERAPY monitored for serum potassium and renal function.
In patients already taking an MRA, such therapy
The approach to managing long-term therapy during can generally be continued during an episode of
hospitalization for acute heart failure (HF) differs for acute decompensation, with appropriate monitoring
HF with reduced ejection fraction (HFrEF) and HF of blood pressure, renal function, and electrolytes.
with preserved ejection fraction (HFpEF). For patients not taking a mineralocorticoid receptor
Approach to long-term therapy for heart failure with antagonist who have an indication for therapy, initia-
preserved ejection fraction tion is advised few days prior to discharge to monitor
serum potassium levels. In patients in whom an ACE
The general principles for treatment of HFpEF are inhibitor or ARB was started or uptitrated shortly prior
control of systolic and diastolic hypertension, control to discharge, it is recommended that mineralocorti-
of heart rate (particularly in patients with atrial fibrilla- coid receptor antagonist initiation be delayed until
tion), control of pulmonary congestion and peripheral the first outpatient visit and evaluation of potassium.
edema with diuresis (with care to avoid hypotension
and/or left ventricular outflow obstruction), and coro- Newer vistas for AHF treatment in CAD( ACS) setting
nary revascularization in patients with coronary heart -IABP ECMO , LVAD
disease with ischemia judged to impair diastolic func- Cardiogenic shock is an acute emergency, which is
tion. Patients with small LV cavities and/or LVH are classically managed by medical support with inotro-
volume-sensitive and at risk for developing hypoten- pes or vasopressors and frequently requires invasive
sion with diuresis.
ventilation. Mechanical circulatory support is increas-
Approach to long-term therapy for heart failure with ingly being considered to allow for recovery or to
reduced ejection fraction bridge until making a decision or definite treatment.
Several modes and devices of mechanical support
Evidence-based therapy to reduce morbidity and are currently available , of which each has its own
mortality for patients with chronic HFrEF includes an features and advantages.Intuitively the most logical
angiotensin converting enzyme (ACE) inhibitor, sin- treatment in acute coronary syndrome(ACS)- related
gle-agent angiotensin receptor blocker (ARB), or an- AHF would be expeditious coronary revascularisa-
giotensin receptor-neprilysin inhibitor (ARNI); a beta tion, generally with PCI.The use of adjunct support
blocker; and a mineralocorticoid antagonist . Once devices used in the Cath lab in AHF in ACS patients
the patient has stabilized from AHF, evidence-based is by itself a voluminous subject of intense research
therapies are carefully initiated, re-initiated, or titrat- and discussion and details are beyond the scope of
ed with arrangements for appropriate outpatient fol- this article.
low-up. Long-acting drugs, such as ACE inhibitors,
ARBs, or ARNI should be administered with caution Briefly,the intra-aortic balloon pump (IABP) consists
or avoided during the first few hours of hospitaliza- of a catheter-mounted balloon that inflates during di-

GCDC 2017