Morning reading|Acute heart failure is divided into “dry, wet, cold and warm”, when should cardiac drugs be used?

Acute heart failure (HF) is a rapid onset of symptoms and/or signs of heart failure or deterioration. At present, acute heart failure has become the main reason for hospitalization in patients over 65 years old, of which 15% to 20% are new-onset heart failure, and most of them are acute exacerbations of existing heart failure.

For the treatment of heart failure, “strengthening the heart, diuresis, and vasodilator” comes to mind, but most clinicians think that the more scientific approach is “diuresis, dilation , strong heart”. Among them, the use of cardiotonic drugs has always been a clinical concern, such as the timing, dosage and treatment window of inotropic drugs.

First of all, we should understand the classification of cardiotonic drugs, their mechanism of action and contraindications

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Table 1 Mechanisms and contraindications of inotropic drugs

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“China Heart Failure Diagnosis and Treatment Guidelines 2018” states:

According to the presence or absence of congestion (divided into “wet” and “wet”) Patients with acute heart failure can be divided into 4 types: “dry-warm”, “dry-cold”, “wet-warm” and “damp-cold” , of which the “wet warm” type is the most common.

Table 2 Clinical classification of acute heart failure

Most patients with acute heart failure have normal or elevated systolic blood pressure (>140 mmHg, hypertensive acute heart failure), only a few (5% to 8%) Presents with low systolic blood pressure (<90 mmHg, hypotensive acute heart failure). Patients with hypotensive acute heart failure have a poor prognosis, especially when hypoperfusion is also present.

The guidelines also recommend drug treatment according to the classification of acute heart failure. Type to decide whether to use.

(1) Dry-warm type: The cardiac function is not severely damaged, and there is neither clinical manifestations of congestion nor hypoperfusion clinical manifestations. The morbidity population is mainly the mild patients with initial acute heart failure, only manifested as fatigue and mild exertional shortness of breath. The principle of treatment is to treat the primary disease, eliminate the inducement, and prevent the deterioration of the disease; oral drugs can be used.

(2) Warm-humid type: Vasodilators and diuretics are preferred, and cardiac drugs can be used.

(3) Dry-cold type: The body is in a state of low blood volume and the peripheral tissue perfusion is low. If not corrected, use inotropes (eg, digoxin, dobutamine). Diuretics are temporarily withheld, and fluids may even be required; vasoconstrictors (eg, dopamine) may also be used if the patient’s blood pressure is too low.

(4) Cold and wet type: Pulmonary edema, obvious volume overload and peripheral hypoperfusion. If the systolic blood pressure is ≥90 mmHg, vasodilators and diuretics are used first, and inotropic drugs are used when the effect is not good; if the systolic blood pressure is less than 90 mmHg, the first choice is inotropes.

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