1. Emergency?
1.1. RR>25 or accessory muscle use
1.2. PR>130 or <40
1.3. SBP<90 mmHg
1.4. O2 sat<90, on cannula or on tune
1.5. Poor perfusion
2. Supportive
2.1. Bed rest and semi fowler’s position
2.2. Oxygen therapy if O2sat<90%, PaO2<60mmHg
2.3. Morphine if agitate (!!!BP,RR)
2.4. Sodium and fluid restriction
3. Symptomatic treatment: acute HF
3.1. Initial therapy
3.1.1. Decreased Preload
3.1.1.1. Diuretic
3.1.1.1.1. Loop: furosemide, bumetanide, torsemide
3.1.1.1.2. Thiazide
3.1.1.1.3. Spironolactone
3.1.1.1.4. !!Ultraflitration
3.1.1.2. Vasodilator
3.1.1.2.1. Nitroglycerine
3.1.2. Increased contractility (If decrease CO)
3.1.2.1. Inotrope
3.1.2.1.1. 1st: dobutamine: also vasodilator (s/e hypotension)
3.1.2.1.2. 2nd: dopamine
3.1.2.1.3. 3rd: milrinone (if Pt. on beta block)
3.1.3. Decreased Afterload
3.1.3.1. Vasodilator
3.1.3.1.1. Nitroprusside
3.1.3.1.2. ACEI
3.2. แนวทางการจำแนกผู้ป่วย
3.2.1. 1. Congestion: wet or dry; 2. Perfusion: cold or warm
3.2.1.1. Wet and cold
3.2.1.1.1. Inotrope (If BP drop), vasodilator, diuretic
3.2.1.2. Wet and warm (most common)
3.2.1.2.1. Vasodilator, diuretic
3.2.1.3. Dry and cold
3.2.1.3.1. Inotrope or IV fluid
3.2.1.4. Dry and warm
3.2.1.4.1. Adjust drug
4. Specific treatment
4.1. Correction of underlying causes
4.1.1. Revascularization in CAD
4.1.2. Surgical replacement or percutaneous intervention in valvular heart disease
4.1.3. Pericardial drainage and pericardectomy
4.2. Removal of precipitating factors
4.2.1. Correct anemia
4.2.2. Hypertension
4.2.2.1. -
4.2.3. Salt and water restriction
4.3. Improve myocardial function (only in HFrEF) แนะนำ beta block,ACEI ที่ 40, spinorolactone ที่ 35
4.3.1. Initial
4.3.1.1. ACEI
4.3.1.1.1. Effect
4.3.1.1.2. Example: enalapril, captopril
4.3.1.1.3. S/E chronic cough, hypotension, renal failure, hyperkalemia
4.3.1.1.4. Contraindications
4.3.1.2. ARB
4.3.1.2.1. ACEI intolerance (no cough)
4.3.1.2.2. S/E hypotension, renal failure, hyperkalemia
4.3.1.2.3. Contraindications
4.3.1.2.4. Example losartan, irbesartan
4.3.1.3. Beta-blocker
4.3.1.3.1. Example nebivolol, bisoprolol, carvedilol, metoprolol succinate
4.3.1.3.2. No or minimal current evidence of fluid retantion (compensated HF)
4.3.1.3.3. Effect
4.3.1.3.4. Contraindications
4.3.2. Additional
4.3.2.1. Mineralocorticoid antagonist (MRA)
4.3.2.1.1. Example spinorolactone, eplerenone
4.3.2.1.2. Recommend in post-STEMI
4.3.2.1.3. Contraindications
4.3.2.2. Angiotensin receptor-neprilysin inhibitor
4.3.2.3. Ivabradine
4.3.2.3.1. Pt. on max dose of beta block
4.3.2.3.2. Decrease HR (if beta block failed ในการลด HR)
4.3.2.3.3. ลด HR ได้ 10
4.3.2.3.4. Funny channel
4.3.2.4. Digoxin