p.57 抽出テキスト

.............................................................................

continuous infusion. However, they may also be given as repeated boluses. Nitroglycerine can be given as 12 mg boluses in severely hypertensive patients with acute pulmonary oedema.477 Care should be taken to avoid hypotension due to an excessive decrease in preload and afterload. For this reason, they should be used with extreme caution in patients with LVH and/or severe aortic stenosis. However, favorable effects were described in patients with LV systolic dysfunction and aortic stenosis when vasodilators were given with careful monitoring of haemodynamic parameters.481

11.3.5 Inotropes Inotropes are still needed for treatment of patients with low cardiac output and hypotension (Table 22). They should be reserved for patients with LV systolic dysfunction, low cardiac output and low SBP (e.g. <90 mmHg) resulting in poor vital organ perfusion. However, they must be used with caution starting at low doses and uptitrating them with close monitoring.387,388 Inotropes, especially those with adrenergic mechanisms, can cause sinus tachycardia, increase ventricular rate in patients with AF, may induce myocardial ischaemia and arrhythmias, and increase mortality.387,388,430,478 Levosimendan or type-3-phosphodiesterase inhibitors may be preferred over dobutamine for patients on beta-blockers as they act through independent mechanisms.482,483 Excessive peripheral vasodilation and hypotension can be major limitations of type-3-phosphodiestaerase inhibitors or levosimendan, especially when administered at high doses and/or when commenced with a bolus dose.482,484

11.3.6 Vasopressors Vasopressors used for the treatment of AHF are reported in Table 22. Among drugs with a prominent peripheral arterial vasoconstrictor action, norepinephrine may be preferred in patients with severe hypotension. The aim is to increase perfusion to the vital organs. However, this is at the expense of an increase in LV afterload. Therefore, a combination of norepinephrine and inotropic agents may be considered, especially in patients with advanced HF and cardiogenic shock. Some studies, though with limitations, support the use of norepinephrine as first choice, compared with dopamine or epinephrine. Dopamine was compared with norepinephrine as a first-line vasopressor therapy in patients with shock and was associated with more arrhythmic events and with a greater mortality in patients with cardiogenic shock but not in those with hypovolaemic or septic shock. Although the trial included 1679 patients, significance was seen only in a subgroup analysis of the 280 patients with cardiogenic shock and <10% of the patients had MI. As there were no data regarding revascularization, this limits the generalizability of the results.485 In another prospective randomized trial epinephrine was compared with norepinephrine in patients with cardiogenic shock due to acute MI.486 The trial was stopped prematurely due to a higher incidence of refractory shock with epinephrine. Epinephrine was also associated with higher heart rate and lactic acidosis. Despite limitations related to its relatively small sample size, short time of follow-up and lack of data regarding the maximum reached dose, the study suggests superior efficacy and safety with norepinephrine. These data are consistent with a meta-analysis including 2583 patients with cardiogenic shock showing a three-fold increase in the risk of death with epinephrine, compared with norepinephrine, in patients with cardiogenic shock.487 However, the lack of information about dose, duration of treatment, and aetiology, makes these results partially explorative.

11.3.7 Opiates Opiates relieve dyspnoea and anxiety. They may be used as sedative agents during non-invasive positive pressure ventilation to improve patient adaptation. Dose-dependent side effects include nausea, hypotension, bradycardia, and respiratory depression. Retrospective

Table 22 Inotropes and/or vasopressors used to treat acute heart failure

Drug Infusion rate Dobutamine 220 lg/kg/min (betaþ) Dopamine 35 lg/kg/min; inotropic (betaþ) >5 lg/kg/min: inotropic (betaþ), vasopressor (alphaþ) Milrinone 0.3750.75 lg/kg/min Enoximone 520 lg/kg/min Levosimendan 0.1 lg/kg/min, which can be decreased to 0.05

or increased to 0.2 lg/kg/min

Norepinephrine 0.21.0 lg/kg/min Epinephrine 0.050.5 lg/kg/min ESC 2021

Recommendations for the initial treatment of acute heart failure

Recommendations Classa Levelb

Oxygen and ventilatory support Oxygen is recommended in patients with SpO2 <90% or PaO2 <60 mmHg to correct hypoxaemia. I C Intubation is recommended for progressive respiratory failure persisting in spite of oxygen administration or non-invasive ventilation.448 I C Non-invasive positive pressure ventilation should be considered in patients with respiratory distress (respiratory rate >25 breaths/min, SpO2 <90%) and started as soon as possible in order to decrease respiratory distress and reduce the rate of mechanical endotracheal intubation.448 IIa B Diuretics Intravenous loop diuretics are recommended for all patients with AHF admitted with signs/symptoms of fluid overload to improve symptoms.145 I C Combination of a loop diuretic with thiazidetype diuretic should be considered in patients with resistant oedema who do not respond to an increase in loop diuretic doses.145 IIa B Vasodilators In patients with AHF and SBP >110 mmHg, i.v. vasodilators may be considered as initial therapy to improve symptoms and reduce congestion.475477,479,480 IIb B

Continued ................................................................................................ Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026