Heart Failure Management | ||||||
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Transition Care
This phase is important to ensure a safe transition to chronic therapy and discharge from hospital.
Patients on Diuretic Therapy Alone
Once a stable situation has been achieved then:
- Switch to oral furosemide by increasing the intravenous dose by 25% e.g. 20 mg intravenous is equivalent to 25 mg orally. If necessary also introduce a thiazide diuretic (hydrochlorothiazide or metolazone)
- Introduce Carvedilol (daily dosage if EF < 25% and twice a day if EF > 25%). Carvedilol is the preferred β blocker as it is non selective and also blocks alpha receptors thus inhbiting vasoconstriction. β blockers may require an increase in diuretic therapy as they can increase congestion
- Maintain dose for 48 hours, check renal function and NT-proBNP. If they are normal introduce Enalapril
Restrictive Physiology
- The combination of a loop diuretic with an MRA is preferable. Consideration given to prescribing a SGLT2i
- ACEi should be used in low doses
- Propranolol is preferred in HOCM to Carvedilol, as it has no α effect and so has less effect on reducing peripheral vascular resistance
- If the patient is on an esmolol infusion, after 72 hrs, when patient is stable start propranolol and wean the esmolol infusion
- Bisoprolol is a good option if tachycardia is the main issue (high affinity for β1 receptors) or in older patients as usually dosed daily
Patients on Inotrope Therapy
After 72 hours stability undertake repeat investigations including NT-proBNP, SVO2 (central venous catheter or MostCare®) and the echocardiogram.
If everything is satisfactory:
- Reduce adrenergic inotropes slowly
- Once adrenergic inotropes are weaned and the patients is "dry", wean milrinone to 0.5 mcg/kg/min and continue while β blockers introduced.
- Introduce Carvedilol (daily dosage if EF < 25% and twice a day if EF > 25%). Note B blockers may require an increase in diuretic therapy as they can increase congestion
- Continue milrinone for at least 48 hrs after β blockers commenced and then reduce milrinone 0.1 mcg/kg/hr every 24 hours until 0.3 mcg/kg/hr, then stop
- Maintain β blocker dose for 48 hours, check renal function and NT-proBNP. If they are acceptable introduce Enalapril
- When patient is stable with no congestion convert to oral diuretics, as above
Review the need for:
- Anticoagulation - if the EF< 35% give aspirin
- ICD implantation may be indicated in some patients as their risk of sudden cardiac arrest (death) may be increased
- Cardiac Resynchronisation Therapy may improve cardiac function in some patients, particularly those wth a single lead pacemaker or CHD. It is less effective in cardiomyopathy. Hill et al published a helpful review Cardiac Resynchronization Therapy in Pediatrics in 2018 and the Heart Rhythm Society is currently preparing the 2023 HRS/APHRS/LAHRS Guideline on Cardiac Physiologic Pacing for the Avoidance and Mitigation of Heart Failure
Hospital Discharge
Once the patient remains stable for 48 hours, they can be discharged from hospital
Last Updated: May 2023