Initial assessment and management of Acute Heart Failure Syndromes

I am back after a prolonged hiatus and will take a look at the early management of acute heart failure in this post. In a recent commentary published in JAMA, Mihai Gheorghiade and Eugene Braunwald, the doyen of cardiology have proposed a model for the assessment and management of patients presenting with acute heart failure. They consider patients in phase 1 of acute heart failure who require urgent treatment and stabilization.

The patients have been classified in a 6 axis model under the categories of –

1. Clinical severity
2. Blood pressure
3. Heart rate and rhythm.
4. Precipitants
5. Comorbidities
6. De novo or chronic heart failure

Modified from Gheorghiade M, & Braunwald E (2011). A proposed model for initial assessment and management of acute heart failure syndromes. JAMA : the journal of the American Medical Association, 305 (16), 1702-3 PMID: 21521852

I have summarized the model in the form of an algorithm. The grading of congestion is suggested to be done according to a scale available here.

However, there are few questions that remain unanswered.

• The authors caution against the use of inotropes like dobutamine in patients with hypotension but what alternative therapy should be tried is not indicated.
• The authors remark that in patients with concomitant renal abnormality, the interaction between heart failure and renal function is complex and the response to therapy may depend on this interaction but do not comment on the management of these subgroup of patients.

Gheorghiade M, & Braunwald E (2011). A proposed model for initial assessment and management of acute heart failure syndromes. JAMA : the journal of the American Medical Association, 305 (16), 1702-3 PMID: 21521852