TABLE 1.
Current treatment options for acute decompensated heart failure (ADHF)
| Medication | Route and dose | Indication for use | Comments |
|---|---|---|---|
| Diuretics | |||
| Furosemide | 20 mg to 80 mg oral or IV, according to symptoms | Acute diuresis in ADHF | Should be used in concert with vasoactive therapy. Usually 40 mg for every 1.5 creatinine level to max 160 mg |
| Bumetanide | 0.5 mg to 4.0 mg oral or IV, according to symptoms | Acute diuresis in ADHF | Better absorption than furosemide in edematous states; 1:40 dose conversion with furosemide |
| Torsemide | 10 mg to 40 mg oral or IV | ADHF | |
| Acetazolemide | 0.5 mg oral or IV | Severe alkalosis associated with diuresis | Must closely observe creatinine and electroytes |
| Diuretics – refractory congestion | |||
| Metolazone | 2.5 mg to 10 mg oral | Severe refractory CHF | Potent kaliuretic: closely observe creatinine and electroytes |
| Furosemide | IV infusion 5 mg/h to 20 mg/h | Refractory to bolus diuretic therapy | Prolonged infusion may result in hearing loss and profound electrolyte imbalance |
| Nitroglycerin preparations | |||
| Sublingual 0.4 mg, or buccal isosorbide dinitrate 3 mg every 5 min | Clinical decompensated heart failure, SBP >90 mmHg | For use in severe heart failure, prehospital use, hold for SBP <90 mmHg | |
| IV, 50 mg/250 mL D5W, start at 3–5 mL/h, titrate q 5 min for SBP reduction 20% from baseline | Clinical decompensated heart failure, SBP >90 mmHg | Not formally tested in ADHF, optimal dosage not known. Low doses frequently used, hold for SBP <90 mmHg | |
| Natriuretic peptides | |||
| Nesiritide | Bolus 2 μg/kg, then 0.01 μg/kg/min for 24 h to 48 h | ADHF, SBP >100 mmHg | Hypotension not common but may persist >40 min |
| Narcotics | |||
| Morphine | 3 mg IV bolus | ADHF with distress or restlessness | Avoid overdosing, but usually well tolerated; also causes vasodilation and reduction in heart rate |
| Inotropic drugs – to be used only in ADHF refractory to diuretics and vasodilators | |||
| Dopamine | 1 μg/kg/min to 3 μg/kg/min IV | ‘Renal’ dose | Central venous access, continuous BP monitoring required |
| 3 μg/kg/min to 20 μg/kg/min | To support BP and cardiac output | ||
| Dobutamine | 2 μg/kg/min to 20 μg/kg/min | To support cardiac output | Continuous ECG monitoring needed, increases myocardial oxygen consumption |
| Milrinone | 50 μg/kg bolus over 15 min then 0.25 mg/kg/min to 0.75 mg/kg/min infusion | ADHF refractory to diuretics and vasodilators | Routine administration in ADHF associated with increased side effects |
BP Blood pressure; D5W Dextrose 5% in water; ECG Electrocardiogram; IV Intravenous; SBP Systolic blood pressure