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Emergency Medicine: Cardiology 213

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  1. Acute Coronary Syndromes: A Focus on STEMI
    10 Topics
    3 Quizzes
  2. Acute decompensated heart failure
    10 Topics
    3 Quizzes
  3. Hypertensive Urgency and Emergency Management
    11 Topics
    3 Quizzes
  4. Acute aortic dissection
    9 Topics
    2 Quizzes
  5. Arrhythmias (Afib, SVT, VTach)
    10 Topics
    2 Quizzes

Participants 206

  • April
  • Alyssa
  • Ashley
  • Amber
  • Sherif
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The priorities in management include:

  • Respiratory support
  • Hemodynamic stabilization
  • Congestion relief
  • Restoration of adequate perfusion
  • Limiting organ injury
  • Monitoring for arrhythmias
  • Planning hospital discharge and follow-up

Desired Outcomes

  • Relief of congestive symptoms
  • Restoration of adequate end-organ perfusion
  • Optimization of volume status and hemodynamic stability
  • Minimization of further cardiac damage and adverse drug reactions
  • Appropriate initiation/titration of guideline-directed medical therapies

General Approach

  • Discontinue medications worsening heart failure (e.g. NSAIDs, thiazolidinediones)
  • Initiate intravenous loop diuretics for congestion, using 1-2.5 times oral dose
  • Continue beta-blockers and other guideline-directed medical therapies if possible
  • Select additional therapies based on hemodynamic profile

Pharmacologic Therapy

  • Diuretics: Loop diuretics (e.g. furosemide, bumetanide) are first-line for volume overload. May need combination with thiazide diuretics for diuretic resistance.
  • Vasodilators: Nitroglycerin, nitroprusside – Used for rapid symptom relief in hypertensive ADHF with pulmonary edema.
    •   Hemodynamic effects:  ↓ PCWP, ↓ SVR, ↓ MAP, ↑ CO
  • Inotropes: Dobutamine, milrinone – Reserved for cardiogenic shock refractory to other measures. Increase contractility and cardiac output.
  • Vasopressors: Norepinephrine, dopamine – Used in conjunction with inotropes for hypotensive shock with low blood pressure.
  • Other agents: Morphine avoided due to risks. Vasopressin antagonists used for severe hyponatremia.

Non-pharmacologic Therapy

  • Oxygenation/ventilation support
  • Ultrafiltration for diuretic resistance
  • Mechanical circulatory support devices in refractory shock
  • Cardiac transplantation or left ventricular assist devices in advanced heart failure
SubsetPrimary Treatment
Subset I:  “Warm and Dry”: Optimize PO heart failure regimenGOAL
Subset II:  “Warm and Wet”: Provide symptomatic relief from congestionDIURETIC
Subset III:  “Cold and Dry”: Increase perfusion to vital organs to alleviate symptomsFLUIDS
Subset IV:  “Cold and Wet”: Alleviate congestion and hypoperfusionINOTROPE OR VASOPRESSOR + DIURETIC