Heart failure reviews
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Heart failure reviews · Jun 2007
ReviewAlgorithm for therapeutic management of acute heart failure syndromes.
As for other critically ill diseases, two key factors may markedly improved morbidity and mortality of acute heart failure syndromes (AHFS): early initiation of treatment and tailored therapy. Early initiation aims to stop the negative cascade of heart dysfunction. ⋯ Among the proposed treatments, non-invasive ventilation is the only treatment that was consistently proven to be beneficial on morbidity and mortality in almost all types of AHFS. Concerning pharmacological agents, actions should be taken to increase the use of vasodilators and reduce the use of diuretics.
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Acute heat failure syndromes are a heterogenous group of conditions. Chronic heart failure exacerbations represent the vast majority of cases. Pathophysiologic mechanisms, such as hypotension with peripheral tissue hypoperfusion, renal function impairment and myocardial ischemia and injury, adversely affect patients' clinical outcome. ⋯ The calcium sensitizer levosimendan is a new cardiac enhancer that seems to be more effective than classical inotropes in improving cardiac mechanical efficiency and reducing congestion, without causing cardiomyocyte death or increasing myocardial oxygen uptake. Recent randomized trials showed that levosimendan is not superior to placebo or dobutamine in improving 1- and 6-month mortality, although it caused a greater reduction of neurohormonal response. More data are needed regarding patient selection and the optimum regimen and dosing of levosimendan before this treatment modality become the first line therapy of acutely decompensated chronic heart failure patients.
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Acute Heart Failure is a major cause of hospitalisation, with a rate of death and complications. New guidelines have been developed in order to diagnose and treat this disease. Despite these efforts pathophysiology and treatments options are still limited. ⋯ Cardiac output monitors from the pulmonary artery catheter to the pulse pressure analysis and Doppler techniques are discussed, with focus on this specific clinical setting. Undoubtedly monitoring is valuable tool, but without a protocol of how to manipulate the haemodynamics, no monitor will prove alone to be beneficial. Haemodynamic driven early goal directed therapy are largely awaited in this field of medicine.
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Most patients with acute heart failure present with increased left ventricular filling pressure and high or normal blood pressure; only a minority present with cardiogenic shock. In this context, therapy with vasodilators in the acute setting can improve both hemodynamics and symptoms. Vasodilators are usually given in conjunction with diuretics, although much of the acute effect of loop diuretics may be due to venodilation. ⋯ Angiotensin-converting enzyme (ACE) inhibitors have vasodilatory effects, but intravenous infusion of enalapril within 24 h of ischemic chest pain is not recommended. Oral ACE inhibition may be used to reduce afterload in other settings if blood pressure permits. Use of calcium antagonists in acute heart failure is not recommended.
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Non-invasive ventilation (NIV) refers to the delivery of mechanical ventilation to the lungs using techniques that do not require an endotracheal airway. Essentially, there are two modalities: continuous positive airway pressure (CPAP) and pressure support ventilation (NIPSV). In acute pulmonary edema (APE) both modalities have shown a faster improvement in gas exchange and physiologic parameters with respect to conventional oxygen therapy. ⋯ The ventilator is usually set at 5 cmH(2)O of EPAP and inspiratory pressure between 12 and 25 cmH(2)O, although initially, the level of pressure support is lower. It is essential to achieve a good adaptation and synchronicity between the patient and the ventilator, reducing leakage to a minimum. The use of facial masks, high FiO(2), and sedation with opiates are complementary maneuvers that may be recommended in this context in the majority of patients.