Acute heart failure

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

hemodynamically stable

1st line – oxygen therapy

Plus – loop diuretic

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Plus –

loop diuretic

Treatment recommended for ALL patients in selected patient group

Mainstay of treatment and effective in relieving symptoms.[1][2][73] Intravenous agents (bolus or continuous infusion) are indicated on initial hospitalization in patients with evidence of pulmonary congestion and volume overload.[1][2]

Patients already taking oral loop diuretics should be started on a higher dose intravenously (may require double their usual dose), with further titration as needed.[2][66] Diuretic response should be evaluated shortly after start of diuretic therapy, initially with hourly urine output measurement; ongoing monitoring should include careful measurement of 24-hour fluid intake and output, vital signs, and standing body weight measured at the same time each day.[1][2]

The most commonly used agent appears to be furosemide, but some patients may respond more favorably to another loop diuretic (e.g., bumetanide). Once stabilized, patients should be switched to an appropriate dose of an oral diuretic at the minimum dose required to relieve congestion, keep the patient asymptomatic, and maintain a dry weight (when the patient is euvolemic).

Diuretics should be used only in combination with other medical therapies.[2]

Primary options

furosemide: 40-160 mg/dose intravenously initially, increase by 20-40 mg/dose every 6-12 hours according to response, maximum 600 mg/day

bumetanide: 0.5 to 2 mg intravenously once or twice daily initially, increase dose according to response, maximum 10 mg/day

Plus – supportive care

Consider – vasodilator

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Consider –

vasodilator

Treatment recommended for SOME patients in selected patient group

Vasodilators (e.g., nitroglycerin, nitroprusside) are often used in acute heart failure to relieve symptoms of pulmonary congestion in patients without systemic hypotension; however, they do not improve long-term outcomes (i.e., reduction of mortality or rehospitalization).[1][2]

Nitroglycerin is preferred in emergency settings.[34] Nitroprusside is usually given in the intensive care setting where enhanced monitoring is available (e.g., invasive hemodynamic blood pressure monitoring), due to its potential for marked hypotension and risk of cyanide toxicity.[2] Dose of nitroprusside exceeding 400 micrograms/minute generally does not produce added benefit and may increase the risk of thiocyanate toxicity.[102]

Primary options

nitroglycerin: 5 micrograms/minute intravenously initially, increase by 5-20 micrograms/minute increments every 3-5 minutes according to response, maximum 100 micrograms/minute

Secondary options

nitroprusside: 0.3 micrograms/kg/minute initially, titrate according to response, maximum 10 micrograms/kg/minute for 10 minutes

Consider – nonloop diuretic

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Consider –

nonloop diuretic

Treatment recommended for SOME patients in selected patient group

Nonloop diuretics may be added if there is an inadequate response to loop diuretics alone.[2] Options include acetazolamide, hydrochlorothiazide, metolazone, or acute use of aldosterone antagonists such as spironolactone and eplerenone.[74][75]

Careful monitoring of renal function and electrolytes is essential when loop and nonloop diuretics are used in combination.

The minimum dose of diuretics should be used to relieve congestion, keep the patient asymptomatic, and maintain a dry weight (when the patient is euvolemic).

Primary options

acetazolamide: 250-375 mg orally/intravenously once daily initially, adjust dose according to response

hydrochlorothiazide: 25-100 mg orally once daily

spironolactone: 25-100 mg orally once daily

eplerenone: 25-50 mg orally once daily

metolazone: 2.5 to 10 mg orally once daily

Consider – extracorporeal ultrafiltration

Consider – mechanical circulatory support (MCS)

Consider – ventilation

due to cardiac ischemia

Plus – antiplatelet agent ± revascularization

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Plus –

antiplatelet agent ± revascularization

Treatment recommended for ALL patients in selected patient group

Aspirin is given to all patients (in the absence of contraindication) with coronary ischemia and those undergoing revascularization in combination with a P2Y12 inhibitor (e.g., clopidogrel, prasugrel, ticagrelor).[80] A P2Y12 inhibitor is recommended, in addition to aspirin, for 12 months unless there are contraindications such as excessive risk of bleeding. Thereafter aspirin is continued indefinitely.

Revascularization may be achieved with percutaneous revascularization or, in selected cases, with coronary artery bypass grafting.

See Overview of acute coronary syndrome.

Primary options

aspirin: 162-325 mg orally as a loading dose, followed by 75-100 mg once daily thereafter

-- AND --

clopidogrel: 300-600 mg orally as a loading dose, followed by 75 mg once daily

prasugrel: 60 mg orally as a loading dose, followed by 10 mg once daily

ticagrelor: 180 mg orally as a loading dose, followed by 90 mg twice daily

due to cardiac arrhythmia

Consider – consideration for anticoagulation ± rate/rhythm control, or pacing

due to valvular disease

Consider – consideration for surgery ± vasodilator

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Consider –

consideration for surgery ± vasodilator

Treatment recommended for SOME patients in selected patient group

The definitive treatment for aortic stenosis or mitral stenosis is valve replacement, but in resistant heart failure a percutaneous valvotomy may be used as a temporary measure until definitive valve replacement is carried out. In mitral stenosis, percutaneous valvuloplasty may be done if no thrombus is present on transesophageal echocardiogram.

With careful monitoring, vasodilator therapy (e.g., nitroprusside) may benefit patients with aortic stenosis, aortic regurgitation, mitral stenosis, or mitral regurgitation who are not hypotensive, provided they are not already on a vasodilator for another indication.

Nitroprusside is usually given in the intensive care setting where enhanced monitoring is available (e.g., invasive hemodynamic blood pressure monitoring), due to its potential for marked hypotension and risk of cyanide toxicity.[2] Dose of nitroprusside exceeding 400 micrograms/minute generally does not produce added benefit and may increase the risk of thiocyanate toxicity.[102]

See Aortic stenosis, Aortic regurgitation, Mitral stenosis, and Mitral regurgitation.

Primary options

nitroprusside: 0.3 micrograms/kg/minute initially, titrate according to response, maximum 10 micrograms/kg/minute for 10 minutes

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Plus –

vasoactive drugs

Treatment recommended for ALL patients in selected patient group

Patients with hypotension (systolic BP <90 mmHg) or shock should be commenced on vasoactive drugs (a vasopressor and/or inotrope).[1]

Cardiogenic shock is characterized by critical reduction in cardiac output and end-organ hypoperfusion in a patient with a systolic BP <90 mmHg.[2]

Vasoactive agents may cause tachycardia, and induce arrhythmias and myocardial ischemia.[1][2]

The preferred vasopressor agent is norepinephrine (noradrenaline).[1][2]

Inotropes (e.g., dobutamine, milrinone) should be used with caution because there is evidence that they result in increased mortality.[1][2][13] Inotropes should be discontinued if there are sustained arrhythmias or symptomatic coronary ischemia. Continuous monitoring of cardiac rhythm is recommended during infusion of inotropes. There is a lack of robust evidence to suggest a clear benefit of one inotropic agent over another in cardiogenic shock.[2][78]

Selection of appropriate vasoactive agents may vary according to clinician preference and local practice guidelines.

Consult a specialist for guidance on suitable regimens.

Plus – supportive care

Consider – ventilation

2nd line – temporary mechanical circulatory support (MCS)

due to cardiac ischemia

Plus – aspirin ± revascularization

due to valve stenosis

Consider – percutaneous valvotomy

hypertensive crisis

1st line – oxygen therapy

Plus – intravenous nitroglycerin

Consider – nitroprusside

Plus – supportive care

Consider – ventilation

ONGOING

acute episode stabilized: LVEF <50%

1st line – renin-angiotensin system inhibitor

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1st line –

renin-angiotensin system inhibitor

For patients with reduced left ventricular ejection fraction (LVEF), a combination of drugs from all four of the following medication classes should be commenced, increased rapidly to maximum recommended and tolerated doses, and continued long-term: renin-angiotensin system inhibitors (i.e., angiotensin-II receptor antagonist/neprilysin inhibitor, ACE inhibitor, or an angiotensin-II receptor antagonist); a beta-blocker; an aldosterone antagonist; and a sodium-glucose cotransporter 2 [SGLT2]) inhibitor.[2][68][91]

There is increasing evidence that patients with mildly reduced ejection fraction (LVEF 41% to 49%) benefit from the same therapies as patients with reduced ejection fraction (LVEF <40%), including use of an angiotensin-II receptor antagonist/neprilysin inhibitor (e.g., sacubitril/valsartan) or an ACE inhibitor.[1][2][68][95][97] An angiotensin-II receptor antagonist is recommended if ACE inhibitors are not tolerated and use of an angiotensin-II receptor antagonist/neprilysin inhibitor is not feasible.

Treatment with sacubitril/valsartan is recommended both as a first-line treatment for patients newly diagnosed with acute heart failure, and to replace ACE inhibitor (or angiotensin-II receptor antagonist) therapy in patients with chronic symptomatic heart failure with reduced ejection fraction.[2] Patients with HFmrEF should have repeat evaluation of LVEF to determine the trajectory of their disease process.[2]

Dose should be increased to the maximum tolerated dose depending upon blood pressure and heart rate.

Primary options

sacubitril/valsartan: treatment-naive or treatment-experienced on a low dose: 24 mg (sacubitril)/26 mg (valsartan) orally twice daily initially, increase gradually according to response, maximum 97 mg (sacubitril)/103 mg (valsartan) twice daily; treatment-experienced on a usual dose: 49 mg (sacubitril)/51 mg (valsartan) orally twice daily initially, increase gradually according to response, maximum 97 mg (sacubitril)/103 mg (valsartan) twice daily

Patients not taking an ACE inhibitor or angiotensin-II receptor antagonist (treatment-naive) or those on a low dose of an ACE inhibitor or angiotensin-II receptor antagonist should be started on a lower dose of sacubitril/valsartan. Patients who were being treated with an ACE inhibitor or angiotensin-II receptor antagonist (treatment-experienced) at a usual dose should be started on a higher dose of sacubitril/valsartan.

Allow 36 hours between stopping an ACE inhibitor and starting this drug.

captopril: 6.25 to 50 mg orally three times daily

lisinopril: 2.5 to 40 mg orally once daily

ramipril: 1.25 to 10 mg orally once daily

enalapril: 2.5 to 20 mg orally twice daily

Secondary options

candesartan cilexetil: 4-32 mg orally once daily

losartan: 25-150 mg orally once daily

valsartan: 40-160 mg orally twice daily

Plus – beta-blocker

Plus – aldosterone antagonist

Plus – sodium-glucose cotransporter 2 (SGLT2) inhibitor

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Plus –

sodium-glucose cotransporter 2 (SGLT2) inhibitor

Treatment recommended for ALL patients in selected patient group

There is evidence to support the long-term use of an SGLT2 inhibitor in patients with reduced LVEF (both HFrEF and HFmrEF), regardless of whether the patient has type 2 diabetes mellitus.[1][2][66][68][92][95][96][97] They should be started before discharge when possible.[66] Patients with diabetes taking SGLT2 inhibitors are at increased risk of developing diabetic ketoacidosis (including euglycemic ketoacidosis).[30]

Primary options

dapagliflozin: 10 mg orally once daily

empagliflozin: 10 mg orally once daily

sotagliflozin: 200-400 mg orally once daily

Consider – vasodilator

Consider – loop diuretic ± nonloop diuretic

Back

Consider –

loop diuretic ± nonloop diuretic

Treatment recommended for SOME patients in selected patient group

Patients who have evidence of volume overload or pulmonary congestion are continued on loop diuretics.

Most patients with decreased left ventricular function will need long-term diuretics, whereas those with primary diastolic heart failure will usually not need to be kept on maintenance diuretics.

In patients with reduced left ventricular ejection fraction, diuretics should be used only in combination with other medical therapies, such as an ACE inhibitor (or an angiotensin-II receptor antagonist or an angiotensin-II receptor antagonist/neprilysin inhibitor), a beta-blocker, and an aldosterone antagonist.[2]

Loop diuretics used for the treatment of acute heart failure and congestion include furosemide, bumetanide, and torsemide. The most commonly used agent appears to be furosemide, but some patients may respond more favorably to another loop diuretic (e.g., bumetanide, torsemide). Nonloop diuretics, such as metolazone, may be added if there is an inadequate response to loop diuretics alone.[2]

Careful monitoring of renal function and electrolytes is essential when loop and nonloop diuretics are used in combination.[2] The minimum dose of diuretics should be used to relieve congestion, keep the patient asymptomatic, and maintain a dry weight. In both acute heart failure and stable congestive heart failure, loop diuretics are the preferred agent. Almost all patients with heart failure will be treated with loop diuretics, but in patients with hypertension and only mild fluid retention, a thiazide diuretic may be considered.[2]

Primary options

furosemide: 40-160 mg/dose orally/intravenously initially, increase by 20-40 mg/dose every 6-12 hours according to response, maximum 600 mg/day

bumetanide: 0.5 to 2 mg orally/intravenously once or twice daily initially, increase dose according to response, maximum 10 mg/day

torsemide: 10-20 mg orally once daily initially, increase dose according to response, maximum 200 mg/day

furosemide: 40-160 mg/dose orally/intravenously initially, increase by 20-40 mg/dose every 6-12 hours according to response, maximum 600 mg/day

bumetanide: 0.5 to 2 mg orally/intravenously once or twice daily initially, increase dose according to response, maximum 10 mg/day

torsemide: 10-20 mg orally once daily initially, increase dose according to response, maximum 200 mg/day

-- AND --

metolazone: 2.5 to 10 mg orally once daily

Consider – digoxin

Consider – ivabradine

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Consider –

ivabradine

Treatment recommended for SOME patients in selected patient group

Treatment with ivabradine in stable patients with chronic heart failure (i.e., LVEF <35%) and a resting heart rate of >70 bpm - on a background of guideline-based heart failure therapy - is associated with reducing the risk of hospitalization for worsening heart failure.[2][98] In one randomized, double-blind, placebo-controlled trial, addition of ivabradine to standard background therapy did not improve the outcome in patients with stable coronary artery disease without clinical heart failure (no evidence of left ventricular systolic dysfunction, in the overall study population mean ejection fraction was 56.4%). In the subgroup analysis of the study, ivabradine was associated with an increase in the incidence of the primary end point (death from cardiovascular causes or nonfatal myocardial infarction) among patients who had angina of Canadian Cardiovascular Society class II or higher but not among patients without angina or those who had angina of class I. Ivabradine was associated with an increased incidence of bradycardia, QT prolongation, and atrial fibrillation.[99]

Primary options

ivabradine: 5 mg orally twice daily initially, may increase to 7.5 mg twice daily after 2 weeks if necessary

Plus – supportive care

acute episode stabilized: LVEF ≥50%

1st line – control of blood pressure and optimal management of other comorbidities

Plus – sodium-glucose cotransporter 2 (SGLT2) inhibitor

Back

Plus –

sodium-glucose cotransporter 2 (SGLT2) inhibitor

Treatment recommended for ALL patients in selected patient group

There is increasing evidence to support the long-term use of an SGLT2 inhibitor in patients with mildly reduced or preserved LVEF, regardless of whether the patient has type 2 diabetes mellitus.[1][2][66][68][92][94][95][96][97] Patients with diabetes taking SGLT2 inhibitors are at increased risk of developing diabetic ketoacidosis (including euglycemic ketoacidosis).[30]

Primary options

dapagliflozin: 10 mg orally once daily

empagliflozin: 10 mg orally once daily

sotagliflozin: 200-400 mg orally once daily

Consider – loop diuretic ± nonloop diuretic

Back

Consider –

loop diuretic ± nonloop diuretic

Treatment recommended for SOME patients in selected patient group

If needed, diuretics may be prescribed to reduce congestion and improve symptoms.[2]

In both acute heart failure and stable congestive heart failure, loop diuretics are the preferred agent. Almost all patients with heart failure will be treated with loop diuretics, but in patients with hypertension and only mild fluid retention a thiazide diuretic may be considered.[2]

Loop diuretics used for the treatment of acute heart failure and congestion include furosemide, bumetanide, and torsemide. The most commonly used agent appears to be furosemide, but some patients may respond more favorably to another loop diuretic. Nonloop diuretics, such as metolazone, may be added if there is an inadequate response to loop diuretics alone.[2]

Primary options

furosemide: 40-160 mg/dose orally/intravenously initially, increase by 20-40 mg/dose every 6-12 hours according to response, maximum 600 mg/day

bumetanide: 0.5 to 2 mg orally/intravenously once or twice daily initially, increase dose according to response, maximum 10 mg/day

torsemide: 10-20 mg orally/intravenously once daily initially, increase dose according to response, maximum 200 mg/day

furosemide: 40-160 mg/dose orally/intravenously initially, increase by 20-40 mg/dose every 6-12 hours according to response, maximum 600 mg/day

bumetanide: 0.5 to 2 mg orally/intravenously once or twice daily initially, increase dose according to response, maximum 10 mg/day

torsemide: 10-20 mg orally/intravenously once daily initially, increase dose according to response, maximum 200 mg/day

-- AND --

metolazone: 2.5 to 10 mg orally once daily

Consider – durable mechanical circulatory support (MCS)

Plus – supportive care

Use of this content is subject to our disclaimer

Acute heart failure

Treatment algorithm

hemodynamically stable

oxygen therapy

loop diuretic

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

supportive care

vasodilator

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

nonloop diuretic

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

extracorporeal ultrafiltration

mechanical circulatory support (MCS)

ventilation

due to cardiac ischemia

antiplatelet agent ± revascularization

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

due to cardiac arrhythmia

consideration for anticoagulation ± rate/rhythm control, or pacing

due to valvular disease

consideration for surgery ± vasodilator

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

due to acute right heart failure

treatment of underlying cause

due to acute myocarditis

supportive care or immunosuppressant therapy

hypotensive (systolic BP <90 mmHg)

oxygen therapy

vasoactive drugs

supportive care

ventilation

temporary mechanical circulatory support (MCS)

due to cardiac ischemia

aspirin ± revascularization

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

due to valve stenosis

percutaneous valvotomy

hypertensive crisis

oxygen therapy

intravenous nitroglycerin

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

nitroprusside

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

supportive care

ventilation