Table 5.

Initial treatment of cardiogenic pulmonary edema.

✓Supplemental oxygen and/or non-invasive ventilatory support to assure adequate oxygenation in case of hypoxemia

✓Early intravenous loop diuretics (i.e., furosemide) therapy is considered the cornerstone of CPE in order to decrease cardiac preload; the aggressiveness of diuretic therapy depends on the patient’s hemodynamic and volume status

✓Vasodilator therapy when the initial response to diuretics is not sufficient to decrease cardiac preload (e.g., nitroglycerin). Early intravenous vasodilator therapy with an agent that lowers arterial tone (e.g., nitroprusside) is suggested in patients who require a rapid decrease in cardiac afterload (e.g., those with severe hypertension, acute mitral regurgitation, acute aortic regurgitation).

✓Management of Atrial fibrillation (AF). AF management starts with rate control (<110/min) and early decision-making regarding the need for cardioversion. Anticoagulation prior to cardioversion (e.g., intravenous heparin) is mandatory for patients in whom cardioversion will take place more than 48 h after the onset of AF or when the duration is unknown. In patients with preserved ejection fraction, rate control can be achieved with beta-blockers. In patients who cannot receive a beta blocker, digoxin may be considered.

✓Management of hypotensive patient ◦In patients with reduced ejection fraction, the use of an inotrope (i.e., dobutamine or milrinone) is suggested in the presence of adequate preload. Beta-blockers should be discontinued due to their negative inotropic effect; of note, milrinone does not act via beta receptors; as a consequence, its effects are not as diminished as those of dobutamine by concomitant beta-blocker therapy). In case of persistent shock, a vasopressor (i.e., phenylephrine or norepinephrine) may be needed ◦Patients with preserved ejection fraction may require a vasopressor and should not receive inotropic therapy. Assessment of the intravascular volume status is critical in such patients to determine the need for hydration. For patients with dynamic left ventricular outflow obstruction (e.g., some patients with hypertrophic cardiomyopathy), treatment may also include beta-blockers.

✓Venous thromboembolism prophylaxis

✓Sodium and fluid restriction