Table 3.
Synopsis of Recommended AHF Therapies Based on ESC, HFSA and ACCF/AHA, and CCS Guidelines
| Recommendation | ESC | HFSA | ACCF/AHA | CCS |
|---|---|---|---|---|
| Diuretic use | ||||
| AHF patients with fluid overload should receive diuretics | I/B | B | I/B | SR/MQ |
| Dosing | IV, to symptom improvement, consider high-dose regimen, NSR. | IV, titrate to symptom relief, minimize AE (C) | Initial IV dose should equal or exceed oral daily dose, then adjust based on response (I/B) | We recommend a loop diuretic, such as furosemide, for most patients with HF and congestive symptoms. When acute congestion is cleared, the lowest dose should be used that is compatible with stable signs and symptoms (SR/LQ). |
| Inadequate diuresis | Consider doubling loop diuretic (NSR) Consider adding thiazide Consider dopamine @ 2.5 μg/kg/min (NSR) |
Increase dose (C) Continuous infusion (C) Add thiazide (C) |
Add thiazide (IIa/B) Increase loop dose (IIa/B) Consider renal dose dopamine (IIb/B) |
Increases in loop diuretics, cautious addition of a second diuretic (a thiazide or low-dose metolazone) (WR/MQ). |
| Ultrafiltration | Consider in refractory cases (NSR) | Refractory cases (C) In lieu of diuretics—selected patients (C) |
In refractory cases of overload (IIb/B) Pulmonary congestion (IIb/C) |
Patients with persistent congestion despite diuretic therapy, with or without impaired renal function, may, under experienced supervision, receive continuous venovenous ultrafiltration. (Practical tip) |
| Vasodilators, other pharmacologic therapy | Titrated to SBP > 100 mm Hg, for relief of dyspnea in hemodynamically stable patients (SBP > 100 mm Hg) | |||
| Nitrates | In pulmonary congestion and SBP >110 mm Hg (IIa/B) caution in aortic/mitral stenosis | + diuretic and no hypotension (B) | + diuretic therapy (IIb/A) | SR/MQ |
| Nesiritide | NSR | After first-line therapy(C) | + diuretic therapy (IIb/A) | WR/HQ |
| Vasopressin antagonist | NSR | NSR | Severe volume overload and Na < 135 (IIb/B) | Symptomatic or severe hyponatremia (<130 mmol/L) and persistent congestion despite standard therapy, to correct hyponatremia and the related symptoms (WR/MQ) |
| Opiates +/− antiemetic | IIa/C | NSR | NSR | NSR |
| Fluid restriction | NSR | <2 L/days if Na < 130 mEq/L; stricter if <125 mEq/L (C) | 1.5–2 L/day especially in Na < 135 and congestion (IIa/C) | NSR |
| Thromboembolism prophylaxis | I/A | If no contraindication (B) | UFH, LMWH (I/B) | NSR |
| Respiratory support | ||||
| Oxygen | If SaO2 < 90% (I/C) | If hypoxia (C) | NSR | If hypoxia, titrated to an SaO2 > 90% (SR/MQ) |
| NIV | For RR > 20, caution in SBP < 85 mm Hg (IIa/B) | In severe dyspnea (A) | NSR | We recommend CPAP or BiPAP not be used routinely (SR/MQ) |
| Inotropic support | SBP < 85 mm Hg or hypoperfusion (IIa/C) | In selected hypotensive patient (C) | In short-term support of selected patients (IIb/B) | We recommend hemodynamically stable patients do not routinely receive inotropes like dobutamine, dopamine, or milrinone (SR/HQ). |
ACCF/AHA = American College of Cardiology Foundation/American Heart Association; AHF = acute heart failure; BiPAP = bilevel positive airway pressure; CCS = Canadian Cardiovascular Society; CPAP = continuous positive airway pressure; ESC = European Society of Cardiology; HFSA = Heart Failure Society of America; NIV = noninvasive ventilation; NSR= no specific recommendation; SR/HQ = strong recommendation, high-quality evidence; SR/LQ = strong recommendation, low-quality evidence; SR/MQ = strong recommendation, moderate-quality evidence; WR/HQ = weak recommendation, high-quality evidence; WR/MQ = weak recommendation, moderate-quality evidence.