ACUTE HEART FAILURE AFTER ACUTE HEART FAILURE AFTER MYOCARDIAL INFARCTIONMYOCARDIAL INFARCTION
Nurkić Midhat MD PhD FESCNurkić Midhat MD PhD FESC
• In most patients with heart failure due to left In most patients with heart failure due to left ventricular systolic dysfunction, the underlying ventricular systolic dysfunction, the underlying
cause is coronary heart diseasecause is coronary heart disease
• To reduce progression to heart failure in a To reduce progression to heart failure in a
patient with acute myocardial infarction, it is patient with acute myocardial infarction, it is important to achieve the earliest possible important to achieve the earliest possible
reperfusion, whether by thrombolysis or primary reperfusion, whether by thrombolysis or primary percutaneous coronary interventionpercutaneous coronary intervention
ACUTE HEART FAILUREACUTE HEART FAILURE
Sudden development of a large Sudden development of a large myocardial infarction or rupture of a myocardial infarction or rupture of a
cardiac valve in a patient who cardiac valve in a patient who previously was entirely wellpreviously was entirely well
LV Remodelling Post MILV Remodelling Post MIAcute infarctionAcute infarction
(hours)(hours)
Infarct expansionInfarct expansion(hours to days)(hours to days)
Global remodellingGlobal remodelling(days to months)(days to months)
• Acute heart failure (AHF) is the one of the Acute heart failure (AHF) is the one of the most common disorders encountered in most common disorders encountered in
medical practice, and is associated with a medical practice, and is associated with a high mortality and morbidity rate despite high mortality and morbidity rate despite
contemporary therapy contemporary therapy
Kannel et al, 1979Kannel et al, 1979
00 11 22 33 44 55 66 77 88 99DaysDays
Cumulative HF (%)Cumulative HF (%)
3030
2525
2020
1515
1010
55
00
YearsYears
TimeTime
10103030
Heart Failure after Acute MIHeart Failure after Acute MI
1 week1 week
EDV: 137 ml ESV: 80 mlEDV: 137 ml ESV: 80 mlEF: 41%EF: 41%
3 months3 months
EDV: 189 ml ESV: 146 mlEDV: 189 ml ESV: 146 mlEF: 23%EF: 23%
LV Remodelling Post Anteroseptal MILV Remodelling Post Anteroseptal MI
Apical 4 chamber view: End diastoleApical 4 chamber view: End diastole
Sharpe N. 2000Sharpe N. 2000
Heart failureHeart failure
• Clinical syndrome that may result from any Clinical syndrome that may result from any structural or functional cardiac disorder that structural or functional cardiac disorder that
impairs the pumping ability of the heartimpairs the pumping ability of the heart
• It not only reduces life expectancy but is It not only reduces life expectancy but is associated with symptoms of breathlessness, associated with symptoms of breathlessness, fluid retention and fatigue that markedly impair fluid retention and fatigue that markedly impair
quality of lifequality of life
Adapted from Cohn JN. N Engl J Med. 1996;335:490–498.
Pathologicremodeling
Low ejectionfraction Death
Symptoms:DyspneaFatigueEdema
Chronicheartfailure
•Neurohormonalstimulation
•Endothelial dysfunction
•Myocardial toxicity
SuddenDeath
Pump failure
Coronary artery disease
Hypertension
Cardiomyopathy
Valvular disease
Myocardialinjury
Pathologic Progression of CV DiseasePathologic Progression of CV Disease
Diabetes
Explosive Increase in HFExplosive Increase in HFAHA.Heart Disease and Stroke Statistics – 2005 UpdateAHA.Heart Disease and Stroke Statistics – 2005 Update
• 1979 – 2002: Hospital discharges from HF rose from 1979 – 2002: Hospital discharges from HF rose from 377,000 to 970,000 per year377,000 to 970,000 per year
• 1992 – 2002: Deaths increased 35.3%1992 – 2002: Deaths increased 35.3%
• Number of patients with HF is expected to double in 30 Number of patients with HF is expected to double in 30 yearsyears
Similarities Between Acute MI and Acute Similarities Between Acute MI and Acute Decompensated HF in the USDecompensated HF in the US
(Gheorghiade M, et al. Circulation 2005;112:3958-68)(Gheorghiade M, et al. Circulation 2005;112:3958-68)
Acute MIAcute MI ADHFADHF
IncidenceIncidence 1 million per year1 million per year 1 million per year1 million per year
MortalityMortality
In-hospitalIn-hospital 3–4%3–4% 3–4%3–4%
After discharge (60–90 After discharge (60–90 d)d) 2%2% 10%10%
Pathophysiological Pathophysiological target(s)target(s)
Clearly defined Clearly defined (coronary (coronary
thrombosis)thrombosis)UncertainUncertain
Clinical benefits of Clinical benefits of interventions in published interventions in published clinical trialsclinical trials
BeneficialBeneficialMinimal/no benefit or Minimal/no benefit or
deleterious compared with deleterious compared with placeboplacebo
ACC/AHA ACC/AHA recommendationsrecommendations
ManyManyLevel ALevel A NoneNone
Natural History of Chronic and Acute Natural History of Chronic and Acute Heart FailureHeart Failure
Initial phaseInitial phase Last yearLast year
Normal heartNormal heart Chronic heart failureChronic heart failure5 million in the US5 million in the US
10 million in Europe10 million in Europe
DeathDeath
Initial Initial myocardial myocardial
injuryinjury
First ADHF episode:First ADHF episode:Pulmonary edemaPulmonary edema
ER admissionER admission
Later ADHF episodes:Later ADHF episodes:Rescue therapyRescue therapyICU admissionICU admission
What if fluid overload What if fluid overload causes progressive HF?causes progressive HF?
Gheorghiade M. Am J Cardiol. 2005;96(suppl 6A):1-4G.Gheorghiade M. Am J Cardiol. 2005;96(suppl 6A):1-4G.
Hea
rt V
iab
ility
Hea
rt V
iab
ility
Mechanism of Worsening HF with Renal Mechanism of Worsening HF with Renal DysfunctionDysfunction
Renal dysfunction
(Schrier RW. JACC 2006;47:1-8)
Acutely Decompensated Heart Failure (ADHFAcutely Decompensated Heart Failure (ADHF))
♥ ♥ How to predict mortality?How to predict mortality? ♥ ♥ What do these patients look like?What do these patients look like? ♥ ♥ How do you know how much to diurese?How do you know how much to diurese? ♥ ♥ Is BNP useful in judging diuresis?Is BNP useful in judging diuresis? ♥ ♥ How to use diureticsHow to use diuretics ♥ ♥ What do you do when the creatinine What do you do when the creatinine increases? increases? ♥ ♥ Is ultrafiltration useful?Is ultrafiltration useful? ♥ ♥ ACE-inhibitors or beta-blockers first?ACE-inhibitors or beta-blockers first? ♥ ♥ Should beta-blockers be started in hospital?Should beta-blockers be started in hospital? ♥ ♥ When should you use intravenous therapy?When should you use intravenous therapy?
Current Treatment of Heart FailureCurrent Treatment of Heart Failure
Copyright restrictions may apply.
Fonarow, G. C. et al. JAMAFonarow, G. C. et al. JAMA 2005;293:572-580.2005;293:572-580.
Predictors of In-
Hospital Mortality
Heart Failure Risk Scoring SystemHeart Failure Risk Scoring System
Lee, D. S. et al. JAMA 2003;290:2581-2587.
Lee, D. S. et al. JAMA 2003;290:2581-2587.
Mortality Rates in Acutely Decompensated Heart Failure by Risk Score
They’re Sicker Than We ThinkThey’re Sicker Than We Think
•In-hospital: 3%In-hospital: 3%•30-day: 7.9%30-day: 7.9%
•One year: 30%One year: 30%•Five years: Five years: 60%60%
Baker, DW et al. Am Heart J 2003; 146(2): 258-64Baker, DW et al. Am Heart J 2003; 146(2): 258-64
Ho KK, et al. Circulation 1993; 88(1): 107-15Ho KK, et al. Circulation 1993; 88(1): 107-15
Jong P, et al. Arch Int Med 2002; 162(15) 1689-94Jong P, et al. Arch Int Med 2002; 162(15) 1689-94
Narang R ,et al. Eur Heart J 1996; 17(9) 1390-1403Narang R ,et al. Eur Heart J 1996; 17(9) 1390-1403
Mortality risk after 1Mortality risk after 1stst hospitalization for ADHF: hospitalization for ADHF:(Age, male gender, ischemia and decreased LVEF worsen (Age, male gender, ischemia and decreased LVEF worsen prognosis)prognosis)
Comparative Five Year MortalityComparative Five Year Mortality
• Adenocarcinoma of the colon (IIIB): 36%Adenocarcinoma of the colon (IIIB): 36%
• COPD (FEVCOPD (FEV11 30-39% predicted): 53% 30-39% predicted): 53%
• ESRD (dialysis-dependent): 60-80%ESRD (dialysis-dependent): 60-80%
Acutely Decompensated Heart Failure (ADHFAcutely Decompensated Heart Failure (ADHF))
♥ ♥ How to predict mortality?How to predict mortality? ♥ ♥ What do these patients look like?What do these patients look like? ♥ ♥ How do you know how much to diurese?How do you know how much to diurese? ♥ ♥ Is BNP useful in judging diuresis?Is BNP useful in judging diuresis? ♥ ♥ How to use diureticsHow to use diuretics ♥ ♥ What do you do when the creatinine What do you do when the creatinine increases? increases? ♥ ♥ Is ultrafiltration useful?Is ultrafiltration useful? ♥ ♥ ACE-inhibitors or beta-blockers first?ACE-inhibitors or beta-blockers first? ♥ ♥ Should beta-blockers be started in hospital?Should beta-blockers be started in hospital? ♥ ♥ When should you use intravenous therapy?When should you use intravenous therapy?
Current Treatment of Heart FailureCurrent Treatment of Heart Failure
Congestion in HF: Congestion in HF: Most Admitted Patients are “Wet”Most Admitted Patients are “Wet”
(ADHERE Registry. 3rd Qtr 2003 National Benchmark Report.)(ADHERE Registry. 3rd Qtr 2003 National Benchmark Report.)
89%
74%67% 65%
34%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Any Dyspnea PulmonaryCongestion
(CXR)
Rales PeripheralEdema
Dyspnea at Rest
Ad
mit
ted
Pat
ien
ts (
%)
<<
I I I I I I I I II I I I I I I I I
Time Course of Events Preceding Time Course of Events Preceding ADHF HospitalizationADHF Hospitalization
-90 -25 -20 -15 -10 -5 -90 -25 -20 -15 -10 -5 00 5 10 5 10 I I I I I I I I IIII I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I
Days Days
Admission Admission
Dyspnea Dyspnea (8-9)(8-9)
Cough Cough (10)(10)
Weight gain Weight gain (11)(11)
Edema Edema (12)(12)
Edema, Edema, Cough,Cough,Fatigue Fatigue (7)(7)
Dyspnea Dyspnea (3)(3)
(-89 to -1)(-89 to -1)
(-25 to -5)(-25 to -5)
(-21 to ?)(-21 to ?)
ePAD ePAD (19)(19)
Thoracic Thoracic Impedance Impedance (15)(15)
SDAAM SDAAM (16)(16)
Rapid Assessment of Hemodynamic StatusRapid Assessment of Hemodynamic Status
Congestion at RestCongestion at Rest
LowLowPerfusionPerfusion
at Restat Rest
NO
NO YES
YES
Signs/Symptoms of Congestion:
Orthopnea / PNDJV DistensionHepatomegalyEdemaRales (rare in chronic
heart failure)Elevated est. PA
systolic( loud P2 and RV lift)
Valsalva square waveAbdominojugular
refluxS3Possible Evidence of Low Perfusion:
Narrow pulse pressure Cool extremitiesSleepy / obtunded Hypotension with ACE inhibitorLow serum sodium Renal Dysfunction (one cause)Elevated LFTs Pulsus alternans
Rapid Assessment of Hemodynamic StatusRapid Assessment of Hemodynamic Status
Congestion at RestCongestion at Rest
LowLowPerfusionPerfusion
at Restat Rest
NO
NO YES
YES
Warm & Dry
Warm & Wet
Cold & Wet
Cold & Dry
Nohria,J Cardiac Failure 2000;6:64
67%
28%5%
Potential Endpoints of Therapy in ADHFPotential Endpoints of Therapy in ADHF
• Resting symptomsResting symptoms• JVDJVD• RalesRales• EdemaEdema• PCW or Cardiac OutputPCW or Cardiac Output• BNPBNP• Echo (mitral regurgitation or PA Echo (mitral regurgitation or PA
pressure)pressure)
(Drazner M, et al. J Heart Lung Tx 1999;1126. Rosario, et al. JACC 1998;1819-24. Johnson, et (Drazner M, et al. J Heart Lung Tx 1999;1126. Rosario, et al. JACC 1998;1819-24. Johnson, et al. Ciruclation 1998 [abstract])al. Ciruclation 1998 [abstract])
Is the Swan-Ganz Catheter Useful in the Is the Swan-Ganz Catheter Useful in the Patient with Acute Decompensated HF?Patient with Acute Decompensated HF?
(Stevenson, et al. JAMA 2005;294:1625-1633)(Stevenson, et al. JAMA 2005;294:1625-1633)
NO
00 66 1212 1818 2424MonthsMonths
00
1010
2020
3030
4040
5050
6060
Total Mortality Risk%Total Mortality Risk%
199199
257257
PCW > 16 mmHgPCW > 16 mmHg
PCW PCW << 16 mmHg 16 mmHg
P=0.001P=0.001
00 66 1212 1818 2424MonthsMonths
00
1010
2020
3030
4040
5050
6060
Total Mortality Risk%Total Mortality Risk%
236236
220220
Cardiac Index > 2.6 L/min-MCardiac Index > 2.6 L/min-M22
Cardiac Index Cardiac Index << 2.6 L/min/M 2.6 L/min/M22
Early Response of PCW but not CI Predicts Early Response of PCW but not CI Predicts Subsequent Mortality in Advanced Heart FailureSubsequent Mortality in Advanced Heart Failure
Final hemodynamic measurement in 456 advanced HF patients after tailored vasodilator therapy Final hemodynamic measurement in 456 advanced HF patients after tailored vasodilator therapy
P=NSP=NS
(Fonarow G Circulation 1994;90:I-488)
Acutely Decompensated Heart Failure (ADHFAcutely Decompensated Heart Failure (ADHF))
♥ ♥ How to predict mortality?How to predict mortality? ♥ ♥ What do these patients look like?What do these patients look like? ♥ ♥ How do you know how much to diurese?How do you know how much to diurese? ♥ ♥ Is BNP useful in judging diuresis?Is BNP useful in judging diuresis? ♥ ♥ How to use diureticsHow to use diuretics ♥ ♥ What do you do when the creatinine What do you do when the creatinine increases? increases? ♥ ♥ Is ultrafiltration useful?Is ultrafiltration useful? ♥ ♥ ACE-inhibitors or beta-blockers first?ACE-inhibitors or beta-blockers first? ♥ ♥ Should beta-blockers be started in hospital?Should beta-blockers be started in hospital? ♥ ♥ When should you use intravenous therapy?When should you use intravenous therapy?
Current Treatment of Heart FailureCurrent Treatment of Heart Failure
BNP is Increased with HF and BNP is Increased with HF and Systolic or Diastolic DysfunctionSystolic or Diastolic Dysfunction
Maisel AS, et al. JACC 2003;41:2010Maisel AS, et al. JACC 2003;41:2010
BNP Levels Pre-discharge Predict Mortality BNP Levels Pre-discharge Predict Mortality and Readmisssionand Readmisssion
(Logeart D, et al. JACC 20042;40:976-82)(Logeart D, et al. JACC 20042;40:976-82)
Acutely Decompensated Heart Failure (ADHFAcutely Decompensated Heart Failure (ADHF))
♥ ♥ How to predict mortality?How to predict mortality? ♥ ♥ What do these patients look like?What do these patients look like? ♥ ♥ How do you know how much to diurese?How do you know how much to diurese? ♥ ♥ Is BNP useful in judging diuresis?Is BNP useful in judging diuresis? ♥ ♥ How to use diureticsHow to use diuretics ♥ ♥ What do you do when the creatinine What do you do when the creatinine increases? increases? ♥ ♥ Is ultrafiltration useful?Is ultrafiltration useful? ♥ ♥ ACE-inhibitors or beta-blockers first?ACE-inhibitors or beta-blockers first? ♥ ♥ Should beta-blockers be started in hospital?Should beta-blockers be started in hospital? ♥ ♥ When should you use intravenous therapy?When should you use intravenous therapy?
Current Treatment of Heart FailureCurrent Treatment of Heart Failure
Sodium Reabsorption Sites in the NephronSodium Reabsorption Sites in the Nephron
Proximal TubuleProximal Tubule70%70%
Distal TubuleDistal Tubule
20%20%
5%5%
1-4%1-4%Loop of HenleLoop of Henle
Collecting T
ubuleC
ollecting TubuleGlomerulusGlomerulus
Thiazide Thiazide DiureticsDiuretics
Loop Loop DiureticsDiuretics
Ceiling Doses of Loop Diuretics (mg)Ceiling Doses of Loop Diuretics (mg)
FurosemideFurosemide bumetanidebumetanide torsemicletorsemicle
IVIV popo IVIV popo IVIV popo
Renal InsufficiencyRenal Insufficiency
moderatemoderate 8080 8080 2-32-3 2-32-3 20-5020-50 20-5020-50
severesevere 200200 240240 8-108-10 8-108-10 50-10050-100 50-10050-100
Cirrhosis with Cirrhosis with
normal GFRnormal GFR4040 80-16080-160 11 11 10-2010-20 10-2010-20
CHF with normal GFRCHF with normal GFR 40-8040-80 160-160-240240 2-32-3 2-32-3 20-5020-50 20-5020-50
(Adapted from Brater C. New Engl J Med 1999)
Bioavailability of Loop DiureticsBioavailability of Loop Diuretics
100%100%
80%80%
50%50%
10%10%
--
--
--
--
furosemidefurosemide torsemidetorsemide bumetanidebumetanide
Acutely Decompensated Heart Failure (ADHFAcutely Decompensated Heart Failure (ADHF))
♥ ♥ How to predict mortality?How to predict mortality? ♥ ♥ What do these patients look like?What do these patients look like? ♥ ♥ How do you know how much to diurese?How do you know how much to diurese? ♥ ♥ Is BNP useful in judging diuresis?Is BNP useful in judging diuresis? ♥ ♥ How to use diureticsHow to use diuretics ♥ ♥ What do you do when the creatinine What do you do when the creatinine increases? increases? ♥ ♥ Is ultrafiltration useful?Is ultrafiltration useful? ♥ ♥ ACE-inhibitors or beta-blockers first?ACE-inhibitors or beta-blockers first? ♥ ♥ Should beta-blockers be started in hospital?Should beta-blockers be started in hospital? ♥ ♥ When should you use intravenous therapy?When should you use intravenous therapy?
Current Treatment of Heart FailureCurrent Treatment of Heart Failure
(de Silva, R. et al. Eur Heart J 2006 27:569-581)(de Silva, R. et al. Eur Heart J 2006 27:569-581)
Baseline Renal Dysfunction and Worsening Renal Function (WRF) are Additive in Predicting Mortality in HF Patients
sCreatinine ≤1.2 1.2-2.0 ≥2.0 ≤1.2 1.2-2.0 ≥2.0WRF (>0.3mg/dL) no no no yes yes yes
And a fall in sCr of >0.3 mg/dL was associated with improved mortality
Predictors of WRF were thiazidediuretics, increased BUN, and vascular disease
What to do when the creatinine begins to What to do when the creatinine begins to increase?increase?
• Check volume statusCheck volume status• Check blood pressure (especially at peak Check blood pressure (especially at peak
onset of vasodilators)onset of vasodilators)• Restrict sodium intake (and water if Restrict sodium intake (and water if
hyponatremic)hyponatremic)• Check for renal problems (obstructions, Check for renal problems (obstructions,
prooteinuria, interstitial nephritis)prooteinuria, interstitial nephritis)• Consider vasodilators or inotropesConsider vasodilators or inotropes• Consider ultrafiltrationConsider ultrafiltration
Ultrafiltration Improved Weight Loss But Ultrafiltration Improved Weight Loss But Not SymptomsNot Symptoms
Costanzo MR. American College of Cardiology 2006 Scientific Sessions; March 12, 2006; Atlanta, GA.
End pointsEnd points UltrafiltrationUltrafiltration DiuresisDiuresis pp
nn 8383 8484
48 hours48 hours
•Weight loss, primary end point Weight loss, primary end point (mean kg)(mean kg)
5.0 5.0 3.1 3.1 0.0010.001
•Dyspnea score, primary end Dyspnea score, primary end point (mean)point (mean)
6.46.4 6.16.1 0.350.35
•Net fluid loss (mean L)Net fluid loss (mean L) 4.64.6 3.33.3 0.0010.001
•K<3.5 mEq/L (%)K<3.5 mEq/L (%) 11 1212 0.0180.018
•Need for vasoactive drugs (%)Need for vasoactive drugs (%) 33 1313 0.0150.015
Ultrafiltration Decreased RehospitalizationUltrafiltration Decreased Rehospitalization
CostanzoCostanzo MR. MR. American College of Cardiology 2006 Scientific American College of Cardiology 2006 Scientific SessionsSessions; March 12, 2006; Atlanta, GA. ; March 12, 2006; Atlanta, GA.
End pointsEnd points UltrafiltrationUltrafiltration DiuresisDiuresis pp
90 days90 days
•Rehospitalization (%)Rehospitalization (%) 1818 3232 0.0220.022
•Rehospitalization days (mean)Rehospitalization days (mean) 1.41.4 3.83.8 0.0220.022
•Unscheduled office/ED visits (%)Unscheduled office/ED visits (%) 2121 4444 0.0090.009
Acutely Decompensated Heart Failure (ADHFAcutely Decompensated Heart Failure (ADHF))
♥ ♥ How to predict mortality?How to predict mortality? ♥ ♥ What do these patients look like?What do these patients look like? ♥ ♥ How do you know how much to diurese?How do you know how much to diurese? ♥ ♥ Is BNP useful in judging diuresis?Is BNP useful in judging diuresis? ♥ ♥ How to use diureticsHow to use diuretics ♥ ♥ What do you do when the creatinine What do you do when the creatinine increases? increases? ♥ ♥ Is ultrafiltration useful?Is ultrafiltration useful? ♥ ♥ ACE-inhibitors or beta-blockers first?ACE-inhibitors or beta-blockers first? ♥ ♥ Should beta-blockers be started in hospital?Should beta-blockers be started in hospital? ♥ ♥ When should you use intravenous therapy?When should you use intravenous therapy?
Current Treatment of Heart FailureCurrent Treatment of Heart Failure
ACE-inhibitor or Beta-blocker First?ACE-inhibitor or Beta-blocker First?CIBIS-III CIBIS-III
(Willenheimer R, et al. Circulation 2005;112:2426-2435)
ACE-inhibitor or Beta-blocker First?ACE-inhibitor or Beta-blocker First?CIBIS-IIICIBIS-III
(Willenheimer R, et al. Circulation 2005;112:2426-2435)
Bisoprolol first
Enalapril first
(HR 0.94, CI = 077-1.16, = = 0.0.019 for noninferiority)
ACE-inhibitor or Beta-blocker First?ACE-inhibitor or Beta-blocker First?CIBIS-IIICIBIS-III
(Willenheimer R, et al. Circulation 2005;112:2426-2435)
(HR 0.88, CI = 0.63-1.22, p = 0.44)
Bisoprolol first
Enalapril first
Survival
ACE-inhibitor or Beta-blocker First?ACE-inhibitor or Beta-blocker First?CIBIS-IIICIBIS-III
(Willenheimer R, et al. Circulation 2005;112:2426-2435)(Willenheimer R, et al. Circulation 2005;112:2426-2435)
Freedom from hospitalization for worsening HF
Bisoprolol first
Enalapril first
(HR = 1.25, CI = 0.87-1.81, p = 0.23)
Acutely Decompensated Heart Failure (ADHFAcutely Decompensated Heart Failure (ADHF))
♥ ♥ How to predict mortality?How to predict mortality? ♥ ♥ What do these patients look like?What do these patients look like? ♥ ♥ How do you know how much to diurese?How do you know how much to diurese? ♥ ♥ Is BNP useful in judging diuresis?Is BNP useful in judging diuresis? ♥ ♥ How to use diureticsHow to use diuretics ♥ ♥ What do you do when the creatinine What do you do when the creatinine increases? increases? ♥ ♥ Is ultrafiltration useful?Is ultrafiltration useful? ♥ ♥ ACE-inhibitors or beta-blockers first?ACE-inhibitors or beta-blockers first? ♥ ♥ Should beta-blockers be started in hospital?Should beta-blockers be started in hospital? ♥ ♥ When should you use intravenous therapy?When should you use intravenous therapy?
Current Treatment of Heart FailureCurrent Treatment of Heart Failure
Goals in the Treatment of the Patient with Goals in the Treatment of the Patient with Acutely Decompensated HFAcutely Decompensated HF
DiureticsDiuretics NesiritideNesiritide MilrinoneMilrinone
Improve symptomsImprove symptoms yes (+++)yes (+++) yes (+)yes (+) ??
Decrease mortalityDecrease mortality ?? ?(?(↑)↑) ?(?(↑)↑)
Decrease hospitalizationDecrease hospitalization
DurationDuration yesyes nono nono
Repeat hospitalizationRepeat hospitalization ?? nono nono
Decreased costsDecreased costs yesyes no(no(↑)↑) no(no(↑)↑)