Treatment of acute decompensated heart failure in acute coronary syndromes
- Wilson S Colucci, MD
Wilson S Colucci, MD
- Section Editor — Heart Failure
- Professor of Medicine
- Boston University School of Medicine
- Section Editors
- Stephen S Gottlieb, MD
Stephen S Gottlieb, MD
- Section Editor — Heart Failure
- Professor of Medicine
- University of Maryland School of Medicine
- James Hoekstra, MD
James Hoekstra, MD
- Section Editor — Adult Cardiology Emergencies
- Professor and Fredrick Glass Chair
- Wake Forest University
Patients with acute decompensated heart failure (ADHF) often have coronary artery disease with or without an acute coronary syndrome . The acute onset of severe myocardial ischemia can lead to a sudden impairment in systolic and diastolic function, resulting in a decreased cardiac output, elevated filling pressures, and the development of pulmonary edema. Flash pulmonary edema can result from myocardial ischemia with or without myocardial infarction (MI).
Specific considerations apply to treatment of ADHF in patients presenting with acute coronary syndromes. The recommendations presented here are generally in agreement with those published in the 2004 American College of Cardiology/American Heart Association (ACC/AHA) ST elevation MI guidelines with 2007 focused update, the 2007 ACC/AHA unstable angina/non-ST elevation MI guideline, and the 2009 focused update of the 2005 ACC/AHA HF guidelines [2-5].
Overall management of acute coronary syndrome and acute MI (including fuller discussion of all therapies including anticoagulant and antiplatelet agents), cardiogenic shock in the setting of acute MI, and general treatment of ADHF are discussed separately. (See "Overview of the acute management of ST elevation myocardial infarction" and "Overview of the acute management of non-ST elevation acute coronary syndromes" and "Prognosis and treatment of cardiogenic shock complicating acute myocardial infarction".)
Management of right ventricular MI which typically presents with hypotension and clear lungs is discussed separately (see "Right ventricular myocardial infarction").
Urgent revascularization is a major component of therapy for patients presenting with ST elevation myocardial infarction (STEMI), and is particularly important for those with heart failure (HF). Early revascularization is indicated for patients presenting with unstable angina/non-ST elevation MI (UA/NSTEMI) and HF. As recommended in the 2009 focused update of the 2005 American College of Cardiology/American Heart Association HF guidelines, urgent cardiac catheterization and revascularization is reasonable when it is likely to prolong meaningful survival in patients with acute HF and known or suspected acute myocardial ischemia due to occlusive coronary disease, especially when there are signs and symptoms of systemic hypoperfusion . (See "Overview of the acute management of ST elevation myocardial infarction" and "Overview of the acute management of non-ST elevation acute coronary syndromes" and "Coronary angiography and revascularization for unstable angina or non-ST elevation acute myocardial infarction" and "Acute ST elevation myocardial infarction: Selecting a reperfusion strategy".)
- Flaherty JD, Bax JJ, De Luca L, et al. Acute heart failure syndromes in patients with coronary artery disease early assessment and treatment. J Am Coll Cardiol 2009; 53:254.
- Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction. www.acc.org/qualityandscience/clinical/statements.htm (Accessed on August 24, 2006).
- Antman, E, Hand, M, Armstrong PW, et al. 2007 Focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction. www.acc.org/qualityandscience/clinical/statements.htm (Accessed on May 02, 2008).
- Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol 2007; 50:e1.
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- Elkayam U, Ng TM, Hatamizadeh P, et al. Renal Vasodilatory Action of Dopamine in Patients With Heart Failure: Magnitude of Effect and Site of Action. Circulation 2008; 117:200.