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Noncardiogenic
Acute
Heart
Failure
AHF
refers
to
rapid
onset
or
worsening
of
symptoms
and/or
signs
of
HF
Most
cases,
pa?ents
with
AHF
present
with
either
preserved
(90140
mmHg)
or
elevated
(>140
mmHg;
hypertensive
AHF)
systolic
blood
pressure
(SBP).
Only
58%
of
all
pa?ents
present
with
low
SBP
(i.e.
,90
mmHg;
hypotensive
AHF),
which
is
associated
with
poor
prognosis
Acute
Pulmonary
Oedema
Diagnos?c
:
1. Respiratory
distress
Respiratory
rate
>
25x/min
or
<
8x/min
Use
of
accessory
muscles
for
breathing
2. Orthopnoea
3. Low
O2
satura?on
<90%
in
oxymetry
4. Pulmonary
rales
bilateral
>
lungs
area
Acute
Pulmonary
Oedema
Diagnos?c
5.
Frothy
sputum,
diaphoresis,
tachycardia
Diagnos?c
Test
Upon
presenta?on
a
measurement
of
plasma
natriure?c
pep?de
level
(BNP,
NT-proBNP
or
MR-
proANP)
is
recommended
in
all
pa?ents
with
acute
dyspnoea
and
suspected
AHF
to
help
in
the
dieren?a?on
of
AHF
from
non-cardiac
causes
of
acute
dyspnoea
(Class
of
Recommenda?on
I,
Level
of
Evidence
A)
Diagnos?c
Test
a.
12-lead
ECG
b.
chest
X-ray
to
assess
signs
of
pulmonary
conges?on
and
detect
other
cardiac
or
non-cardiac
diseases
that
may
cause
or
contribute
to
the
pa?ents
symptoms;
c.
the
following
laboratory
assessments
in
the
blood:
cardiac
troponins,
BUN
(or
urea),
crea?nine,
electrolytes
(sodium,
potassium),
glucose,
complete
blood
count,
liver
func?on
tests
and
TSH.
A.
Cranializa?on
of
Pulmonary
Vasculature
B.
Kerley
Lines
Diagnos?c
Test
Echocardiography
is
recommended
immediately
in
haemodynamically
unstable
AHF
pa?ents
Posi?on
Posi?on
Oxygen
Therapy
and
Ven?latory
Support
Monitoring
of
transcutaneous
arterial
oxygen
satura?on
(SpO2)
is
recommended
Oxygen
therapy
is
recommended
in
pa?ents
with
AHF
and
SpO2
<90%
or
PaO2
<60
mmHg
(8.0
kPa)
to
correct
hypoxaemia
Measurement
of
blood
pH
and
carbon
dioxide
tension
(possibly
including
lactate)
should
be
considered
Oxygen
Therapy
and
Ven?latory
Support
Non-invasive
posi?ve
pressure
ven?la?on
(CPAP,
BiPAP)
should
be
considered
in
pa?ents
with
respiratory
distress
(respiratory
rate
>25
breaths/min,
SpO2
<90%)
Intuba?on
is
recommended,
if
respiratory
failure,
leading
to
hypoxaemia
(PaO2
<60
mmHg
(8.0
kPa)),
hypercapnia
(PaCO2
>50
mmHg
(6.65
kPa))
and
acidosis
(pH
<7.35),
cannot
be
managed
non-
invasively
CPAP
BPAP
Diure?cs
Diure?cs
are
a
cornerstone
in
the
treatment
of
pa?ents
with
AHF
and
signs
of
uid
overload
and
conges?on.
Diure?cs
increase
renal
salt
and
water
excre?on
and
have
some
vasodilatory
eect.
In
pa?ents
with
AHF
and
signs
of
hypoperfusion,
diure?cs
should
be
avoided
before
adequate
perfusion
is
akained
Diure?cs
The
ini?al
approach
to
conges?on
management
involves
i.v.
diure?cs
with
the
addi?on
of
vasodilators
for
dyspnoea
relief
if
blood
pressure
allows.
Diure?cs
Intravenous
loop
Diure?cs
are
recommended
for
all
pa?ents
with
AHF
admiked
with
sign/
symptoms
of
uid
overload
to
improve
symptoms.
(Class
I,
LOE
C)
In
pa?ents
with
new-onset
AHF
or
those
with
chronic,
decompensated
HF
not
receiving
oral
diure?cs
the
ini?al
recommended
dose
should
be
20-40
mg
i.v.
Furosemide
(or
equivalent);
those
on
chronic
diure?c
therapy,
ini?al
i.v.
Doses
should
be
at
least
equivalent
to
oral
dose.
(Class
I,
LOE
B)
Diure?cs
It
is
recommended
to
give
diure?cs
either
as
intermikent
boluses
or
as
a
con?nous
infusion,
and
the
dose
and
dura?on
should
be
adjusted
according
to
pa?ents
symptoms
and
clinical
status.
(Class
I,
LOE
B)
Combina?on
of
loop
diure?c
with
either
thiazide-type
or
spironolactone
may
be
considered
in
pa?ents
with
resistant
oedema
or
insucient
symptoma?c
response
Vasodilators
Intravenous
vasodilators
are
the
second
most
onen
used
agents
in
AHF
for
symptoma?c
relief
They
have
dual
benet
by
decreasing
venous
tone
(to
op?mize
preload)
and
arterial
tone
(decrease
anerload).
Consequently,
they
may
also
increase
stroke
volume.
Vasodilators
Vasodilators
are
especially
useful
in
pa?ents
with
hypertensive
AHF,
whereas
in
those
with
SBP
<90
mmHg
(or
with
symptoma?c
hypotension)
they
should
be
avoided.
Dosing
should
be
carefully
controlled
to
avoid
excessive
decreases
in
blood
pressure,
which
is
related
to
poor
outcome.