Clinical Review ABC of heart failure

Acute and chronic management strategies

BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7234.559 (Published 26 February 2000) Cite this as: BMJ 2000;320:559
  1. T Millane,
  2. G Jackson,
  3. C R Gibbs,
  4. G Y H Lip

    Acute and chronic management strategies in heart failure are aimed at improving both symptoms and prognosis, although management in individual patients will depend on the underlying aetiology and the severity of the condition. It is imperative that the diagnosis of heart failure is accompanied by an urgent attempt to establish its cause, as timely intervention may greatly improve the prognosis in selected cases—for example, in patients with severe aortic stenosis.

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    Survival rates (%) compared with chronic heart failure

    Management of acute heart failure

    Assessment

    Common presenting features include anxiety, tachycardia, and dyspnoea. Pallor and hypotension are present in more severe cases: the triad of hypotension (systolic blood pressure <90 mm Hg), oliguria, and low cardiac output constitutes a diagnosis of cardiogenic shock. Severe acute heart failure and cardiogenic shock may be related to an extensive myocardial infarction, sustained cardiac arrhythmias (for example, atrial fibrillation or ventricular tachycardia), or mechanical problems (for example, acute papillary muscle rupture or postinfarction ventricular septal defect).

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    Killip classification

    Chest × ray film in patient with acute pulmonary oedema

    Severe acute heart failure is a medical emergency, and effective management requires an assessment of the underlying cause, improvement of the haemodynamic status, relief of pulmonary congestion, and improved tissue oxygenation. Clinical and radiographic assessment of these patients provides a guide to severity and prognosis: the Killip classification has been developed to grade the severity of acute and chronic heart failure.

    Treatment

    Basic measures should include sitting the patient in an upright position with high concentration oxygen delivered via a face mask. Close observation and frequent reassessment are required in the early hours of treatment, and patients with acute severe heart failure, or refractory symptoms, should be monitored in a high dependency unit. Urinary catheterisation facilitates accurate assessment of fluid balance, while arterial blood gases provide valuable information about oxygenation and acid-base balance. The …

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