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180 Cardio Diabetes Medicine 2017

for volume overload . • For selected patients with severe HFrEF with acute,
severe hemodynamic compromise, non-durable
• For patients with acute decompensated heart fail- mechanical support is an option.
ure (ADHF) with respiratory distress, respiratory
acidosis, and/or hypoxia with oxygen therapy.a • Patients with HF with preserved ejection fraction
trial of noninvasive ventilation (NIV) is allowed if (HFpEF) presenting with hypotension should not
emergent intubation is not indicated , no contra- receive inotropes and may require a vasopressor in
indications to NIV exist, and personnel with expe- addition to diuretic therapy. Patients who develop
rience in NIV are available. hypotension with dynamic left ventricular outflow
obstruction are treated with beta blocker therapy
• Patients with respiratory failure due to ADHF who and gentle hydration if pulmonary edema is not
fail to improve with NIV (within one-half to two present.
hours), do not tolerate NIV, or have contraindica-
tions to NIV require endotracheal intubation for • Ultrafiltration is an option for patients with HFrEF
conventional mechanical ventilation. or HFpEF with refractory volume overload not re-
sponding to appropriate diuretic strategies.
• In patients with ADHF and fluid overload, initial
therapy should include a loop diuretic (adminis- • Longer term continuation of treatment requires
tered intravenously) .Dosing is individualized, de- careful inititation and maintenance of oral thera-
termined largely by the patient’s renal function and pies after switching from the parenteral ones.
prior diuretic exposure.
In toto, the management of ADHF relies on the FOUR
• Vasodilators may be required to correct elevated PRONGED approach of :
filling pressures and/or LV afterload in patients • determining the “ hemodynamic subset” to
with ADHF. Indications for vasodilator therapy with which the index patient belongs
close hemodynamic monitoring in the setting of
ADHF include the following • instituting acute relief of volume overload un-
der monitored intensive care setting
•For patients with urgent need for afterload reduc-
tion (eg, severe hypertension) or as a temporizing • treatment of precipitant factors of ADHF and
measure in patients with acute aortic regurgitation expiditing revascularisation if need be and
or acute mitral regurgitation, suggest balanced va- • monitored switching of parenteral to oral drugs
sodilator therapy (eg, nitroprusside).
for continuation therapy to prevent AHF recur-
•Vasodilator therapy (eg, nitroglycerin) is started as rences.
an adjunct to diuretic therapy for patients without ad-
equate response to diuretics , and as a component
of therapy for patients with refractory HF and low
cardiac output .

• For most patients hospitalized with ADHF, nesir-
itide is not recommended . In carefully selected
patients with appropriate hemodynamics (includ-
ing absence of hypotension or cardiogenic shock)
who remain symptomatic despite routine therapy,
a trial of nesiritide may be helpful as an alternative
to other vasodilator therapy (nitroglycerin or nitro-
prusside). Nesiritide has a longer effective half-life
than nitroglycerin or nitroprusside, so side effects
such as hypotension may persist longer.
• Treatment of refractory HF and hypotension in
patients with HF with reduced ejection fraction
(HFrEF) is guided by hemodynamics, which is
most commonly imputed from the physical exam-
ination with more direct assessment by selective
right heart catheterization with intravenous inotro-
pic support as a temporizing measure.

GCDC 2017