1. New clinical presentations of acute heart failure (AHF) include acute decompensated heart failure, acute pulmonary edema, isolated right ventricular failure, and cardiogenic shock. 2. Intravenous vasodilators such as nitrates and nitroprusside are recommended to reduce congestion and afterload in AHF patients with increased filling pressures and fluid redistribution to the lungs. 3. Intravenous loop diuretics are recommended for all AHF patients with congestion to improve symptoms, and thiazide diuretics or spironolactone can be added for resistant edema. Inotropic agents may be considered for refractory cases.

1. New clinical presentations of AHF
1.Acute decompensated heart failure
2.Acute pulmonary oedema
3.Isolated right ventricular failure
4.Cardiogenic shock

2. McDonagh et al. 2021. Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal.

3. n
Hypertension Congestion
predominates predominates
“wet and warm” “wet and cold”
(SBP < 90 mmHg)
ESC Guidelines on CHF and AHF, 2016
Diuretic
Vasodilator
Diuretic
Adequate peripheral perfusion?

4. Intravenous vasodilators, namely nitrates or nitroprusside,
dilate venous and arterial vessels leading to
• a reduction in venous return to the heart,
• less congestion,
• lower after-load,
• increased stroke volume
relief of symptoms
i.v. vasodilators may be more effective than diuretics in those patients whose
acute pulmonary oedema is caused by increased afterload and fluid
redistribution to the lungs in the absence or with minimal fluid accumulation

5. Vasodilators Dose
Main side
effects
Other
Start with 10–20
Nitroglycerine µg/min, increase up to
200 µg/min
Hypotension,
headache
Tolerance on
continuous
use
Isosorbide
Start with 1 mg/h,
dinitrate
increase up to 10
mg/h
Hypotension,
headache
Tolerance on
continuous
use
Start with 0.3 Hypotension,
Nitroprusside
µg/kg/min and
isocyanate Light sensitive
increase up to 5 toxicity
µg/kg/min
Ponikowski P, et al. Eur Heart J 2016
Intravenous vasodilators

6. • Loop diuretics are recommended for all patients
with congestion to improve symptoms.
• Combination with either oral thiazide diuretic or
spironolactone may be considered in the
presence of resistant edema or insufficient
symptom response
• May be given as intermittent boluses or
continuous infusion
• Regularly monitor renal function and electrolytes
Intravenous diuretics

7. McDonagh et al. 2021. Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal.

8. “wet and cold”
Adequate peripheral perfusion?
“wet and warm”
ESC Guidelines on CHF and AHF, 2016
Yes No
Vasodilators
Diuretics
Consider inotropic agent
in refractory cases

9. Intravenous inotropes and vasopressors
Inotropes/
Vasopressors
Bolus Infusion rate
Dopamine No
3-5 µg/kg/min
(inotrope)
> 5 µg/kg/min
(vasopressor)
Epinephrine
1 mg can be given
i.v during
resuscitation,
repeated every 3-5
minutes
0.05-0.5 µg/kg/min
Dobutamine No
Norepinephrine No 0.2-1 µg/kg/min