急性代償性心臟衰竭處理 Acute Decompensated Heart Failure Management

臨床評估 Clinical evaluation

初始治療 Initial therapy

#監測生命徵象、心律
Monitor oxygen saturation, vital signs, and cardiac rhythm.

#給氧氣、建立靜脈通路、維持病人挺直坐姿
Provide supplemental oxygen if hypoxic (SpO2 <90%), place 2 IV catheters, and position patient upright.

Provide NIV as needed, unless immediate intubation is required or NIV is otherwise contraindicated; have airway management equipment readily available;

#利尿劑需盡快給予不能拖延，在鬱血性心臟衰竭及體液過多的病人
Initiate diuretic therapy without delay to relieve congestion/fluid overload:

*起手式
1.過去沒使用過利尿劑的病人可以Furosemide 40mg IV(2支)、bumetanide 1mg IV(半支)
2.長期慢性使用利尿劑或腎臟衰竭的病人可能需要用到平常的2倍劑量

#尋找造成急性代償心臟衰竭 (ADEF)的原因並給予相應性的治療，包含 Acute coronary syndrome, Hypertension, Arrhythmia, Acute aortic or mitral regurgitation, Aortic dissection, Sepsis, Renal failure, Anemia, or Drugs

 #心律過快及心房顫動的狀況考慮使用毛地黃digoxin控制心律
Patients with ADHF and AF with rapid ventricular rate often require medication (eg, digoxin) to slow their heart rate.

#若心房顫動合併血液動力學不穩需考慮使用電擊整流
Direct current cardioversion is indicated for patients with new onset AF and hemodynamic instability or refractory symptoms despite rate control.

#在急性主動脈瓣或二尖瓣迴流或升主動脈剝離病人需照會心臟外科處理
Obtain immediate cardiac surgery consultation for acute aortic or mitral regurgitation or ascending aortic dissection.

#End-organ perfusion充足狀況下考慮使用Vasodilator治療
For patients with adequate end-organ perfusion (eg, normal or elevated blood pressure) and signs of ADHF with fluid overload:

*嚴重高血壓、急性主動脈瓣或二尖瓣迴流(Undercircumstances of Severe HTN, MR, AR)考慮使用Nitoprusside
Nitroprusside: 5 to 10 mcg/min and titrate up every 5 minutes as tolerated to a dose range of 5 to 400 mcg/min

*利尿劑使用下仍不足的狀況下考慮使用IV NTG(Undercircumstances of inappropriate diuretics therapy response)
Nitroglycerin(NTG): 5 to 10 mcg/min and titrate every 3 to 5 minutes, range: 10 to 200 mcg/min.

#收縮性心臟衰竭併發ADEF停止beta-blocker使用，嚴重的ADHF或心因性休克，使用IV inotrope，例如 dobutamine或 milrinone (Primacor)，或考慮使用 IABP (Intraaortic balloon counter pulsation)

#LVOT狀況下考慮使用 beta blocker，若有肺水腫考慮使用針劑型利尿劑 ，給予IV vasopressor (eg, phenylephrine or norepinephrine); 禁止給予強心劑或血管舒張劑

#不知心臟狀況之下若有嚴重ADEF且合併心因性休克，給予IV強心劑(eg, dobutamine or milrinone), 給予或不給予IV血管收縮劑(eg, norepinephrine)，並且考慮 Mechanical support如IABP (Intraaortic balloon counter pulsation)

*各種心因性休克病因下之血管收縮作用劑使用選擇 (Circulation, 2017)

Cause or Presentation of CS	Vasoactive Management Considerations
Classic wet and cold	Norepinephrine or dopamine Inotropic agent
Euvolemic cold and dry	Norepinephrine or dopamine Inotropic agent Small fluid boluses
Vasodilatory warm and wet or mixed cardiogenic and vasodilatory	Norepinephrine Consider hemodynamics-guided therapy
RV shock	Fluid boluses Norepinephrine, dopamine, or vasopressin Inotropic agents, Inhaled pulmonary vasodilators
Normotensive shock	Inotropic agent or vasopressor
Aortic stenosis	Phenylephrine or vasopressin In patients with reduced LVEF, echocardiography- or PAC-guided dobutamine titration
Aortic regurgitation	Dopamine Temporary pacing
Mitral stenosis	Phenylephrine or vasopressin Esmolol or amiodarone
Mitral regurgitation	Norepinephrine or dopamine Inotropic agents Temporary MCS, including IABP
Postinfarction ventricular septal defect	See classic wet and cold considerations Temporary MCS, including IABP
Dynamic LVOT obstruction	Fluid boluses, Phenylephrine or vasopressin, Avoid inotropic agents, Avoid vasodilating agents, Esmolol or amiodarone RV pacing
Bradycardia	Chronotropic agents or Temporary pacing
Pericardial tamponade	Fluid bolus Norepinephrine

Ref:
1.Treatment of acute decompensated heart failure: Components of therapy
https://www.uptodate.com/contents/treatment-of-acute-decompensated-heart-failure-components-of-therapy
2.Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association, Circulation. 2017;136:e232–e268. DOI: 10.1161/CIR.0000000000000525