afterload reduction in acute CHF

[obiwan]

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what you heart guys' thoughts about starting something like hydralazine for afterload reduction if patient comes in with decompensated CHF regardless of HFrEF vs HFpEF

 

[DrAwesomo]

Not a heart guy but diuretic (i.e. decreasing preload) and in severe cases, inotropic agents such as dobutamine or primacor is much more important than lowering the afterload unless valvular problem.

 

[nstemi]

afterload reduction is very important to treat in acute chf exacerbation. afterload is essentially the force that the heart has work against to overcome systemic pressures; the more work, the more stress on the heart. we typically use ace-inhibitors/arbs and nitrates. hydralazine can be a nasty long-term drug and we typically use it if someone has a contraindication to ace/arb and/or have class III-IV heart failure who are already maxed on their heart failure regimen.

also inotropes (dobutamine/milrinone) cause vasodilation which reduces afterload.

 

[DrAwesomo]

BP control is definitely important but lowering BP beyond ~125/80 in name of reducing afterload in counterproductive in IMO. If you want to lower afterload, one of the best drug is minoxidil. But those vasodilations cause tachycardia leading to increased mortality forcing FDA to slap a black box warning that you need diuretic and beta blocker on abroad. But in acute CHF increasing beta blocker dose is absolutely the wrong way to go about it.

I am not a big fan of hydralazine. Weak antihypertensive even if you use TID dose. I do use hydralazine and ISDN together if contraindication to Acei/arb or if the patient is black and has very bad CHF.

But again I am not a heart failure/cardiology fellow; so, I'll defer to the experts.

 

[matchpass]

Swan ganz and nitroprusside

 

[happymedgrad]

IV vasodilators are the best treatment in theory for ADHF provided they can be tolerated.

There are 3 problems you can aim to fix: (1)high preload, (2)poor output and (3)high SVR.
Diuretics address the preload problem(1).
Inotropes address the output and therefore the preload(1,2).
Vasodilators address the high SVR which increases CO and decreases preload (1,2,3).

Like the poster above said, nitroprusside is the way to go. Swan maybe helpful but only in the right hands.

In practice most people get diuresed to dry weight and shown the door, with escalation to inotropes if things start to go south (GFR, BP etc). In other words, the reverse of theory based on familiarity and ease of use. In my experience at least.