A review article in the March 13 2007 issue of CMAJ covers the initial evaluation and management and cites the supporting literature. A few points of interest follow.
Loop diuretics: Mainstay of initial therapy; should be combined with other modalities.
Peripheral venous ultrafiltration: Promising, with role in the general care of acute heart failure to be determined.
Nitroglycerine intravenously: Beneficial for patients with adequate blood pressure, underutilized.
Nesiritide: Controversial. Large mortality and cost effectiveness trial about to begin.
CPAP, BiPAP: Now considered first line as initial short term therapy in acute cardiogenic pulmonary edema. (Invasive mechanical ventilation may be more appropriate in some patients presenting with acute myocardial infarction).
Inotropes, PDE inhibitors: Generally avoided and limited to short term palliative use. May increase mortality.
“What to do with long-term ß-blocker therapy in the setting of acute decompensated heart failure remains a clinical conundrum. Our practice is to reduce the dose proportionate to the degree of hemodynamic compromise; the ß-blocker dose may be decreased by about half in patients with evidence of hypoperfusion, and stopped in patients with frank cardiogenic shock, although there is little evidence to support this approach. Following an episode of acute decompensated heart failure, ß-blocker therapy should be titrated upward slowly.”