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 (REF) <40%.