ECG, electrocardiogram; LE, lower extremity; ICU, intensive care un it; IV, intravenous;
PND, paroxysmal nocturnal dyspnea.
0.4 mg every 5 minutes. Severe exacerbations warrant IV
nitroglycerin infusions. Start at a rate between 20 and 50
meg/min and rapidly increase in increments of 20-40
meg/min every 5-10 minutes. Titrate the infusion to
symptomatic relief or systemic hypotension. Consider
nitroprusside in patients who don't adequately respond, as
it is a more potent arterial vasodilator. It is important to
ask any patient requiring vasodilator therapy about the
current use of phosphodiesterase-S inhibitors (eg,
sildenafil, used in erectile dysfunction and pulmonary
hypertension), as the combination of agents may lead to
life-threatening drops in systemic blood pressure. Avoid
opathy, as all are preload dependent conditions.
Initiate IV loop diuretics (eg, furosemide) in all
patients with signs of volume overload. Furosemide is
before the onset of diuresis. Start the dosing at 40 mg IV
in patients naive to the drug, whereas those who take the
agent chronically should have their home dose doubled.
Evaluate patients who fail to diurese within 30 minutes
for any evidence of urinary obstruction and re-dose as
necessary. Bumetanide, torsemide, and ethacrynic acid
are alternative loop diuretics, with ethacrynic acid being
the agent of choice in patients with a history of severe
A summary of medications used to treat acute CHF
exacerbations is listed in Table 15-1.
Table 1 5-1. Med ications used in CHF.
Nitroglycerin 0.4 mg SL Repeat q 3-5 min to
Nitroglycerin IV 25-50 meg/min Titrate by 1 0-20 meg/min
Nitroprusside IV 1 0-20 meg/min Titrate by 5-10 mcgjmin
Furosemide 40-80 mg IV May re-dose at 30 min if no
Bumetanide 1 mg IV May re-dose at 2 hours
Torsemide 10 mg IV May re-dose at 2 hours
Ethacrynic acid 50 mg IV May be re-dosed at 8 hours
Dobutamine 2-5 meg/kg/min Titrate to effect,
Dopamine 3-5 meg/kg/min Titrate to effect,
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