Practical Tips

• In patients at risk or with a prior history of CO2 retention (e.g., chronic obstructive lung disease) permissive hypoxemia may be necessary and can be evaluated with arterial blood gas measurement.
• In situations where intravenous nitroglycerin is not appropriate or available, repeated sublingual nitroglycerin, a nitroglycerin patch, or oral isosorbide dinitrate may be useful for dyspnea relief in patients with a SBP >100 mmHg.
• Intravenous vasoconstrictor agents (e.g., phenylephrine, norepinephrine) should generally be avoided for AHF management unless hypotensive with systolic BP <90 mmHg, associated signs or symptoms and significant change from baseline.
• In patients with low SBP (<90 mmHg), low cardiac output and either euvolemia or hypervolemia, inotropes may be used for stabilization.
• Patients with persistent congestion despite diuretic therapy, with or without impaired renal function, may, under experienced supervision, receive continuous venovenous ultrafiltration.
• ACEi should not be started in the acute setting (e.g. first 8 to 12 hours) unless elevated BP is present and should be initiated after the acute event (e.g. >24 hours), and be continued particularly if the patient is already on chronic ACEi therapy.
• CCB should be avoided as treatment in the setting of reduced ejection fraction (EF) <40%.