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Guidelines for Treating Acute Heart Failure

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Review of: Mebazaa A, Gheorghiade M, Pi a IL, et al: "Practical recommendations for prehospital and early in-hospital management of patients presenting with acute heart failure syndromes." Critical Care Medicine. 36(1 Suppl):S129-139, 2008.

The Science

The authors of this paper said guideline recommendations lack for the management of acute heart failure syndromes in the first six to 12 hours after presentation, which they labeled prehospital and early in-hospital time. "The American College of Cardiology/American Heart Association and European Society of Cardiology guidelines direct the management of these acute heart failure patients, but specific consensus on early management has not been published, primarily because few early management trials have been conducted," they stated.

Therefore a symposium was held where a group of experts reviewed the published literature with the goal of providing a classification of the different forms acute heart failure may manifest itself. Once they accomplished this, they examined data from the Acute Decompensated Heart Failure National Registry (ADHERE) and other databases -- as well as large, multi-center studies -- to suggest a starting point for acute heart failure treatment guidelines.

They proposed a classification of clinical scenarios in acute heart failure syndrome (available in Table 1 of the supplement) and the treatment guidelines that outline management at admission, treatments and treatment objectives within the first 90 to 10 minutes as well as the next six to 12 hours (available in Figure 1 of the supplement).

The Street

This is a very informative article. It's one that every medical director and medic should read. Congestive heart failure (CHF) isn't as simple as we were taught in school. It's a continuum of a disease process, and where the patient is on that continuum will dictate the type of treatment they should receive. The days of simply starting an IV and giving them twice their daily dose of Lasix IV are over.

Some high points the authors stress are that CPAP is for every failure patient with respiratory distress. Nitrates are the first line drug of choice if their blood pressure can handle it, and IV nitrates are preferred. Diruretics should rarely, if ever, be given in the prehospital arena because we usually don't know what the patient's volume status is and whether they're in left- or right-heart failure.

One area in which I disagree with the authors is their discussion of using morphine to assist the patient with CPAP compliance. If you want to treat anxiety, you don't use a narcotic. You use an anxiolytic, such as lorazapam, which is unlikely to suppress respiratory drive as much as morphine. Furthermore, morphine has negative hemodynamic effects that may complicate the failure patient.

The most important fact this paper brings to light is that heart failure can be very difficult to identify. We must be ever vigilant in assessing our patients, particularly those with such vague symptoms as fatigue and weakness.

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