Congestive Heart Failure and Pulmonary Edema

Author Information and Disclosures

Treatment and Medication

Treatment

Prehospital Care:

• Prehospital notification by emergency medical services (EMS) personnel should alert ED staff of a patient presenting with signs and symptoms of CHF and pulmonary edema. They should receive on-line medical advice for patients with high-risk presentations.

• Begin treatment with the ABCs. Administer supplemental oxygen, initially 100% nonrebreather facemask.

• Utilize cardiac monitoring and continuous pulse oximetry.

• Obtain intravenous access, as well as a prehospital ECG, if available.

• Provide nitroglycerin sublingual or spray for active chest pain in the patient without severe hypotension and IV furosemide.

Emergency Department Care:

• Begin ED treatment of a patient presenting with signs and symptoms of CHF and pulmonary edema with the ABCs. Administer supplemental oxygen, initially 100% nonrebreather facemask. Utilize cardiac monitoring and continuous pulse oximetry. Obtain IV access.

• To reduce venous return, elevate the head of the bed. Patients may be most comfortable in a sitting position with their legs dangling over the side of the bed, which allows for reduced venous return and decreased preload.

• Therapy generally starts with nitrates and diuretics if patients are hemodynamically stable. Many other treatment modalities may play some role in acute management.

• If possible, treat the underlying cause as well, if identified. This is particularly necessary for patients with known diastolic dysfunction who respond best to reductions in blood pressure, rather than to diuretics, nitrates, and inotropic agents. Serum BNP levels may be very useful in the setting of undifferentiated dyspnea, or in the future may be useful to gauge therapeutic success.

• Eliminate contributing factors when possible.

• Restrict fluid and sodium.

• Consider other treatment modalities, including nesiritide. Nesiritide may be useful in lieu of nitroglycerin in patients with moderate respiratory distress, particularly if the patient will not tolerate noninvasive ventilation or in the patient who cannot have nitroglycerin by protocol (ie, in an observation unit).

• Continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP)—Recent data comparing nasal CPAP therapy and facemask ventilation therapy have demonstrated decreased need for intubation rates when these modalities are used. In patients with severe CHF treated with CPAP, however, no significant difference was found in short-term mortality rates and length of hospital stay. Although BiPAP therapy may improve ventilation and vital signs more rapidly then CPAP, a higher incidence of MI associated with BiPAP has been reported. BiPAP and CPAP are contraindicated in the presence of acute facial trauma, the absence of an intact airway, and in patients with an altered mental status or who are uncooperative.

• Alternating tourniquets, formerly a mainstay of therapy, have been used to decrease preload. Their use has been supplanted by newer therapies such as intravenous nitroglycerin and nitroprusside.

• Phlebotomy with removal of 500 mL of blood or via plasmapheresis is another former mainstay of therapy used to decrease preload. Its use has been supplanted by newer therapies such as intravenous nitroglycerin and nitroprusside.

Consultations:

• Cardiology

• Critical care services

• Cardiothoracic surgery for possible heart valve surgery or transplantation

Medication

The goal of pharmacotherapy is to achieve a PCWP of 15-18 mm Hg and a cardiac index >2.2 L/min/m², while maintaining adequate blood pressure and perfusion to essential organs. These goals may need to be modified for some patients.

Use of diuretics, nitrates, analgesics, and inotropic agents are indicated for the treatment of CHF and pulmonary edema. Calcium channel blockers, such as nifedipine and nondihydropyridines, increase mortality and increase prevalence of recurrent CHF with chronic use. Conflicting evidence currently exists both in favor of and against the use of calcium channel blockers in the acute setting; at this time limit their acute use to patients with diastolic dysfunction and heart failure, a condition not easily determined in the emergency department.

Angiotensin converting enzyme (ACE) inhibitors, such as SL captopril or IV enalapril, may rapidly reverse hemodynamic instability and symptoms, possibly avoiding an otherwise imminent intubation. Haude compared 25 mg of SL captopril with 0.8 mg of sublingual nitroglycerin in 24 patients with class III and class IV CHF and found that captopril induces a more sustained and more pronounced improvement in hemodynamics. Annane gave 1 mg of IV enalapril to 20 patients presenting with acute class III and class IV CHF over 2 hours and demonstrated rapid hemodynamic improvement with no significant adverse effects on cardiac output or hepatosplanchnic measurements.

Captopril may play a unique role in sustaining patients with renal failure and concomitant acute CHF while awaiting definitive therapy with dialysis. Since the information on this subject is still controversial and limited to small studies, the routine use of ACE inhibitors cannot be recommended at this time. ACE inhibitors remain a promising area in need of further study.

Beta-blockers, possibly by restoring beta-1 receptor activity or via prevention of catecholamine activity, appear to be cardioprotective in patients with depressed left ventricular function. The US Carvedilol Heart Failure study group demonstrated a two-thirds decrease in mortality in patients taking carvedilol with left ventricular ejection fractions of 35% or less. Beta-blockers, particularly carvedilol, have been shown to improve symptoms in patients with moderate-to-severe heart failure. The role of beta-blockers in the acute setting, however, is currently unclear; limit use until hemodynamic studies indicate that further deterioration will not occur.

Because differentiating CHF and asthma exacerbations is often difficult, treating both with the shotgun approach is often used, particularly as both may cause bronchospasm. Aerosolized beta-2 agonists, which are the more selective of beta-agonists, decrease tachycardia, dysrhythmias, and cardiac work while transiently enhancing cardiac function. Terbutaline has been shown to be successful in this setting, as well as albuterol, isoetharine, and bitolterol.

Limit roles of theophylline and aminophylline in the acute setting. They are positive inotropic agents mediated by an increase in catecholamines, and they dilate coronaries and exert mild diuretic effects. Nevertheless, they can exacerbate dysrhythmias (eg, multifocal atrial tachycardia [MAT], ischemia) by increasing cardiac work.

Steroids, IV or PO, have been shown to worsen preexisting heart failure due to systemic sodium retention and volume expansion, hypokalemia, and occasional hypertension. Inhaled steroids, because of their lack of systemic side effects, may be a reasonable option in this confusing patient presentation; however, given their delayed onset of action, they remain an area in need of further study.

Please see the chapter on Asthma for dosing schedules.

Drug Category: Diuretics First-line therapy generally includes a loop diuretic such as furosemide, which will inhibit sodium chloride reabsorption in the ascending loop of Henle.

Furosemide (Lasix) -- Administer loop diuretics IV, since this allows for both superior potency and higher peak concentration despite increased incidence of side effects, particularly ototoxicity.
Adult Dose	A reasonable approach for furosemide might be as follows: 10-20 mg IV for patients symptomatic with CHF not already using diuretics 40-80 mg IV for patients already using diuretics 80-120 mg IV for patients whose symptoms are refractory to the initial dose after 1 h of its administration Higher doses and more rapid redosing may be appropriate for the patient in severe distress
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity, hepatic coma, anuria, severe electrolyte depletion
Interactions	Metformin decreases concentrations; interferes with hypoglycemic effect of antidiabetic agents and antagonizes muscle relaxing effect of tubocurarine; auditory toxicity appears to be increased with coadministration of aminoglycosides; hearing loss of varying degrees may occur; anticoagulant activity of warfarin may be enhanced when taken concurrently; increased plasma lithium levels and toxicity are possible when taken concurrently
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Perform frequent serum electrolyte, carbon dioxide, glucose, creatinine, uric acid, calcium, and BUN determinations during first few months of therapy and periodically thereafter

Metolazone (Mykrox, Zaroxolyn) -- Both chlorothiazide and metolazone have been used as adjunctive therapy in patients initially refractory to furosemide. Chlorothiazide, however, at doses of 250-500 mg IV, decreases GFR with CHF and, thus, is less potent and causes a greater loss of potassium. Conversely, metolazone has been demonstrated to be synergistic with loop diuretics in treating refractory patients.
Adult Dose	5-10 mg PO before redosing with furosemide
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity, hepatic coma, encephalopathy, anuria
Interactions	Thiazides may decrease effect of anticoagulants, sulfonylureas, and gout treatments; anticholinergics and amphotericin B may increase toxicity of thiazides; effects of thiazides may decrease when used concurrently with bile acid sequestrants, NSAIDs, or methenamine; when administered concurrently, thiazides increase toxicity of anesthetics, diazoxide, digitoxin, lithium, loop diuretics, antineoplastics, allopurinol, calcium salts, vitamin D, and nondepolarizing muscle relaxants
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Caution in hepatic or renal disease, diabetes mellitus, gout, or lupus erythematosus

Drug Category: Nitrates --Reduce myocardial oxygen demand by lowering preload and afterload.

In severely hypertensive patients, nitroprusside causes more arterial dilatation than nitroglycerin. Nevertheless, due to thiocyanate toxicity and the coronary steal phenomenon associated with nitroprusside, IV nitroglycerin is still the therapy of choice for afterload reduction.

Nitroglycerin (Nitro-Bid, Nitrol, Nitrostat) -- SL nitroglycerin and nitrospray are particularly useful in the patient who presents with acute pulmonary edema with a systolic blood pressure of at least 100 mm Hg. Similar to SL, nitrospray's onset is 1-3 min with a half-life of 5 min. Applicability of nitrospray may be easier, and storage is up to 4 y. One study demonstrated significant and rapid hemodynamic improvement in 20 patients given nitrospray with pulmonary edema in an ICU setting. Topical nitrate therapy is reasonable in a patient presenting with class I to II CHF. However, in patients with more severe signs of heart failure or pulmonary edema, IV nitroglycerin is preferred since it is easier to monitor hemodynamics and absorption, particularly in the diaphoretic patient. Oral nitrates, due to delayed absorption, have little role in the acute presentations of CHF.
Adult Dose	Nitrospray: single spray (0.4 mg) equivalent to a single 1/150 SL; may repeat q3-5min as hemodynamics permit, up to a maximum of 1.2 mg Ointment: Apply 1-2 inches of nitropaste to chest wall Injection: start at 20 mcg/min IV and rate to effect in 5-10 mcg increments q3-5min
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity, severe anemia, shock, postural hypotension, head trauma, closed-angle glaucoma, cerebral hemorrhage
Interactions	Aspirin may increase nitrate serum concentrations; marked symptomatic orthostatic hypotension may occur with coadministration of calcium channel blockers (dose adjustment of either agent may be necessary)
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Exercise caution with coronary artery disease and low systolic blood pressure.

Nitroprusside sodium (Nitropress) -- Produces vasodilation and increases inotropic activity of the heart. At higher dosages may exacerbate myocardial ischemia by increasing heart rate. Easily titratable.
Adult Dose	10-15 mcg/min IV and titrate to effective dose range of 30-50 mcg/min and a systolic blood pressure of at least 90 mm Hg
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity, subaortic stenosis, optic atrophy, tobacco amblyopia, idiopathic hypertrophic, atrial fibrillation or flutter
Interactions	Patients receiving other hypertensive therapy may be more sensitive to sodium nitroprusside
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in increased intracranial pressure, hepatic failure, severe renal impairment, and hypothyroidism; in renal or hepatic insufficiency, nitroprusside levels may increase and can cause cyanide toxicity; sodium nitroprusside has the ability to lower blood pressure and thus should be used only in those patients with mean arterial pressures >70 mm Hg

Drug Category: Analgesics --Morphine IV is an excellent adjunct in acute therapy. In addition to being both an anxiolytic and an analgesic, its most important effect is venodilation, which reduces preload. Also causes arterial dilatation, which reduces systemic vascular resistance (SVR) and increases cardiac output. Narcan also can reverse the effects of morphine. However, some evidence indicates that morphine use in acute pulmonary edema may increase the intubation rate.

Morphine sulfate (Duramorph, Astramorph, MS Contin) -- DOC for narcotic analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Morphine sulfate administered IV may be dosed in a number of ways and commonly is titrated until desired effect is obtained.
Adult Dose	2-5 mg IV and repeated q10-15min unless respiratory rate is <20 breaths/min or systolic blood pressure is <100 mm Hg
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity, hypotension, potentially compromised airway with uncertain rapid airway control, respiratory depression, nausea, emesis, constipation, urinary retention
Interactions	Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects of morphine
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate

Drug Category: Inotropic agents --Principal inotropic agents include dopamine, dobutamine, inamrinone (formerly amrinone), milrinone, dopexamine, and digoxin. In the hypotensive patient presenting with CHF, dopamine and dobutamine are agents usually used. Inamrinone or milrinone inhibits phosphodiesterase, resulting in an increase of intracellular cyclic AMP and alteration in calcium transport. As a result, they increase cardiac contractility and reduce vascular tone by vasodilatation.

Dopexamine is a new synthetic catecholamine with beta-2 and dopaminergic properties causing vasodilation and increased inotropism but with tachycardia as well. Ultimately may have a role as an emergent inotropic agent, but dobutamine is probably the current agent of choice.

Digoxin has no role in the emergency management of CHF due to delayed absorption and diminished efficacy at times of increased sympathetic tone. Thus, has little, if any, benefit in the patient presenting concomitantly with atrial fibrillation and rapid ventricular response. Limit use of digoxin to chronic CHF in which its role has been well established.

These agents augment both coronary and renal blood flow.

Dopamine (Intropin) -- Stimulates both adrenergic and dopaminergic receptors. Hemodynamic effects depend on the dose. Lower doses stimulate mainly dopaminergic receptors that produce renal and mesenteric vasodilation. Cardiac stimulation and renal vasodilation is produced by higher doses. Positive inotropic agent at 2-10 mcg that can lead to tachycardia, ischemia, and dysrhythmias. Doses >10 mcg cause vasoconstriction, which increases afterload.
Adult Dose	5 mcg/kg/min IV and increase at 5 mcg/kg/min increments to a 20 mcg/kg/min dose
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity, pheochromocytoma, ventricular fibrillation
Interactions	Phenytoin, alpha- and beta-adrenergic blockers, general anesthesia, and MAOIs increase and prolong effects of dopamine
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Monitor closely urine flow, cardiac output, pulmonary wedge pressure, and blood pressure during the infusion; prior to infusion, correct hypovolemia with either whole blood or plasma, as indicated; monitoring central venous pressure or left ventricular filling pressure may be helpful in detecting and treating hypovolemia

Dobutamine (Dobutrex) -- Produces vasodilation and increases inotropic state. At higher dosages may cause increased heart rate, thus exacerbating myocardial ischemia. Strong inotropic agent with minimal chronotropic effect and no vasoconstriction.
Adult Dose	Starting dose: 2.5 mcg/kg/min IV; generally therapeutic in the range of 10-40 mcg/kg/min
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; idiopathic hypertrophic subaortic stenosis; atrial fibrillation or flutter
Interactions	Beta-adrenergic blockers antagonize effects of dobutamine; general anesthetics may increase toxicity
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Following a myocardial infarction use with extreme caution; hypovolemic state should be corrected before using this drug

Drug Category: Human B-type natriuretic peptides --Growing data suggest that Human B-type natriuretic peptides such as Nesiritide may be effective in reducing pulmonary capillary wedge pressure and improving dyspnea in patients with acutely decompensated congestive heart failure. Nesiritide serves as a second messenger to dilate veins and arteries.

Nesiritide (Natrecor) -- Recombinant DNA form of human B-type natriuretic peptides (hBNP), which dilate veins and arteries. Human BNP binds to particulate guanylate cyclase receptor of vascular smooth muscle and endothelial cells. Binding to receptor causes increase in cyclic GMP, which serves as second messenger to dilate veins and arteries. Reduces pulmonary capillary wedge pressure and improves dyspnea in patients with acutely decompensated congestive heart failure.
Adult Dose	2 mcg/kg IV bolus over 60 s; follow by 0.01 mcg/kg/min continuous infusion; bolus volume (mL) = 0.33 X patient weight (kg); infusion flow rate of bolus (mL/h) = 0.1 X patient wt (kg)
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; systolic blood pressure <90 mm Hg; patients suspected of having, or known to have, low cardiac filling pressures, significant valvular stenosis, restrictive or obstructive cardiomyopathy, constrictive pericarditis, pericardial tamponade, conditions in which cardiac output is dependent upon venous return
Interactions	Concurrent administration with ACE inhibitors and other vasodilators may cause hypotension
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Do not initiate at dose higher than recommended; may affect renal function in patients whose renal function may depend on activity of renin-angiotensin-aldosterone system; may cause hypotension (administer in settings where blood pressure can be monitored closely); discontinue drug if hypotension develops; ventricular tachycardia, non-sustained VT, headache, abdominal pain, back pain, insomnia, anxiety, angina pectoris, nausea, and vomiting may occur

• Altitude Illness - Pulmonary Syndromes
• Anaphylaxis
• Anemia, Acute
• Bronchitis
• Chronic Obstructive Pulmonary Disease and Emphysema
• Dysbarism
• Hyperventilation Syndrome
• Myopathies
• Pericarditis and Cardiac Tamponade
• Pneumonia, Aspiration
• Pneumonia, Bacterial
• Pneumonia, Immunocompromised
• Pneumonia, Mycoplasma
• Pneumonia, Viral
• Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum
• Pulmonary Embolism
• Shock, Septic
• Venous Air Embolism

Patient Education

• Heart Center
• Congestive Heart Failure Overview
• Congestive Heart Failure Causes
• Congestive Heart Failure Symptoms
• Congestive Heart Failure Treatment