Management of Acute Decompensated Heart Failure in Hospitalized Patients

Continuous outpatient therapy with inotropes may be a viable option in patients with stage D (end stage) heart failure who are deemed unlikely to survive hospital discharge [45].This is also supported by the ACCF/AHA practice guidelines where IV inotropic support may be considered for the previous reasons only after all alternative therapies to achieve stability have failed (Class IIB indication) [5].

• Is there a role for morphine?

For decades morphine has been considered an essential component in the armamentarium for the treatment of ADHF. Its preload-reducing effect, anti-anxiety properties, and breathlessness suppression has made morphine a popular medication in the treatment of ADHF. Despite its common use, there is a lack of prospective randomized trials demonstrating the safety and benefit of this drug. In a retrospective analysis from the ADHERE database, IV morphine used for ADHF was associated with higher rates of adverse events, including increase use of mechanical ventilation, prolonged hospitalization, increased intensive care unit admissions, and higher mortality, bringing into question its safety profile [46]. Until a randomized trial is completed demonstrating safety and benefit, caution is advised regarding the use of morphine in ADHF.

Case Continued

Over the next 72 hours the patient’s symptoms improved. She no longer has dyspnea at rest, she has had a proper urine-output response to therapy, her serum creatinine has returned to normal, and her vital signs have remained stable. The IV vasodilator was discontinued, dobutamine was weaned off, and the patient was transitioned to guideline-directed medical therapy with an angiotensin-converting enzyme (ACE) inhibitor while continuing IV furosemide. Hospitalized patients who are hemodynamically stable should be transitioned to guideline-directed medical therapy with an oral ACE inhibitor unless the patient has a contraindication, such as marked azotemia or hyperkalemia. Low-dose carvedilol was initiated after optimization of volume status was confirmed. In the absence of shock and after optimization of volume status, every effort should be made to initiate low-dose beta blockers prior to hospital discharge.

• When is mechanical circulatory support indicated in ADHF patients?

Mechanical circulatory support has emerged as a reasonable option in selected patients with acute and reversible cardiogenic shock (ie, acute coronary syndrome or an acute mechanical problem such as a torn papillary muscle or ventricular septal defect) [5]. Recently, the utility of intraaortic balloon pump (IABP) in the setting of cardiogenic shock resulting from acute coronary syndrome was called into question with the negative results from the Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) trial [47]. The study compared IABP with best available medical therapy alone among patients with acute myocardial infarction complicated by cardiogenic shock for who early revascularization was planned. Use of IABP did not reduce 30-day mortality compared with medical therapy in this patient population [47]. Whether IABP has a significant role in mechanical complications, such as acute ventricular septal rupture or papillary muscle rupture, is unknown due to the paucity of data in the management of patients with such complications. Therefore, when patients present with severe acute cardiogenic shock refractory to medical therapy, mechanical circulatory support with either ventricular assist devices (VAD) or extracorporeal membrane oxygenation (ECMO) is the preferred means to reverse terminal circulatory collapse. VADs are effective in the short-term as a “bridge-to-recovery” or as a “bridge-to-decision” when recovery, transplant candidacy, or neurologic status are still uncertain [48,49]. There are several options currently available for mechanical circulatory support, including surgically implanted VADs or the percutaneously implanted VADs, such as the Impella 2.5, 3.5 and 5.0 (Abiomed, Danvers, MA) and the TandemHeart pump (Cardiac Assist, Pittsburgh, PA).The ideal device and optimal duration of temporary support are yet to be defined. A detailed description of the function and clinical effects of mechanical support devices is beyond the scope of this article, although thorough reviews are available [48,49].