The new NICE acute heart failure guideline for acute heart failure in adults is out. Leaves quite a lot of room for interpretation; few hard and fast recommendations. Sizeable section on further research.
In a nutshell:
Have a heart failure team
- Cardiology ward and outreach
Diagnosis
- Rule out heart failure if BNP <100 or NT-proBNP <300.
- Echo those with elevated BNP.
Therapy
No routine opiates and don’t use PA catheters.
1. Stop the beta blocker if shocked, bradycardic on in 3rd degree block
2. Diuresis:
- start or augment
- consider ultrafiltration if diuretic resistant.
3. Nitrates:
- not routinely
- give for concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease. NOT nitroprusside.
4. Inotropes
- not routinely
- use if the cause is reversible – not clear what this means.
5. NIV:
- straight away for cardiogenic pulmonary oedema with dyspnoea AND acidosis.
- consider if respiratory failure not settling, or patient is tiring.
6. Specialist centre involvement
- Discuss early if reversible severe acute heart failure or potential heart transplant recipient.
- Get their valve sorted if that’s the problem!
Once stable
- Beta blocker – watch rate
- ACE – watch renal function
- Aldosterone antagonist
Research recommended
1. Fluid removal
- Dopamine
- Thiazides
- Ultrfiltration
2. Balloon pumps
Comment:
St.Emlyns blog and their recommended reading
