Congestive heart failure acute pharmacotherapy

Overview
The goals of acute treatment of congestive heart failure include:
 * Reduce preload
 * Reduce afterload
 * Reduce intravascular volume
 * Improve cardiac contractility

Mainstays of Therapy

 * Oxygen to improve oxygenation if hypoxemia is present. Continuous positive airway pressure may be applied using a face mask; this has been shown to improve symptoms more quickly than oxygen therapy alone, and has been shown to reduce the risk of death. Severe respiratory failure requires treatment with endotracheal intubation and mechanical ventilation.
 * Diuretics reduce preload and reduce intravascular volume. Intravenous diuretics are often required in the acute setting. If high doses of furosemide are inadequate, boluses or continuous infusions of bumetanide may be preferred. These loop diuretics may be combined with thiazide diuretics such as oral metolazone or intravenous chlorthiazide for a synergistic effect. Intravenous preparations are preferred because of more predictable absorption. When a patient is extremely fluid overloaded, they can develop intestinal edema as well, which can affect enteral absorption of medications.
 * Nitroglycerine reduces afterload and reduces preload. Nitroglycerine is helpful in improving symptoms of dyspnea.
 * Morphine reduces preload, reduces catecholamines, and reduces the stimulation by stretch receptors in the lung thereby improving symptoms of dyspnea.

More Aggressive Pharmacotherapy

 * Nitroprusside reduces afterload and reduces preload

If the patient's circulatory volume is adequate but there is persistent evidence of inadequate end-organ perfusion, inotropes may be administered.
 * Milrinone increases contractility and reduces afterload
 * Dobutamine increases contractility in reduces afterload
 * Dopamine increases blood pressure and increases renal perfusion at low doses
 * Nesiritide reduces afterload and reduces preload and can be used if other therapies have not been effective.