Treatment of Acute Cardiac Cases

Heart failure (HF) can result from a multitude of diseases including congenital cardiac defects and acquired valvular disease, myocardial disease, pericardial disease, disease of the large vessels or severe cardiac arrhythmias. Most often, HF develops gradually over time. However, acute onset of severe valvular regurgitation (e.g. chordal rupture, acute papillary muscle ischaemia, rupture of a valve leaflet), severe primary myocardial disease (e.g. acute myocarditis, ionophore toxicity, acute ischaemia/infarction), aortic root or pulmonary artery rupture, severe pericardial effusion (e.g. pericarditis, trauma, neoplasia, atrial or aortic rupture), or multiform ventricular tachycardia (often associated with severe myocardial disease) may result in sudden onset of acute congestive HF (associated with pulmonary oedema) or cardiogenic shock (characterised by low cardiac output, hypotension, peripheral vasoconstriction, oliguria or anuria, weakness and syncope), requiring immediate emergency treatment.

Emergency treatment of acute congestive heart failure usually aims at immediate preload reduction and symptomatic relief. First choice treatment includes intranasal oxygen and i.v. administration of frusemide, except for cases associated with cardiac tamponade and severe diastolic dysfunction (see below). Dobutamine can be administered as a constant rate infusion to provide acute inotropic support and to improve blood pressures. Afterload reduction should be considered in cases with acute, severe mitral or aortic regurgitation and can be achieved using hydralazine or milrinone, provided that blood pressures can be monitored. After initial stabilisation, long-term therapy with frusemide, digoxin and potentially angiotensin-converting enzyme inhibitors can be started, but limited published experience is available for the latter agents. [...]