الفهرس 
PATHOPHYSIOLOGY of ACUTE HEART FAILURE in ICUOnly 14 pages are availabe for public view
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Abstract
The clinical syndrome of AHF may present as de novo AHF or as decompensated CHF with forward, left (backward), or right (backward) dominance in the clinical syndrome. A patient with AHF requires immediate diagnostic evaluation and care, and frequent resuscitative measures to improve symptoms and survival.
Initial diagnostic assessment should include clinical examination supported by the patient’s history, ECG, chest X-ray, plasma BNP/NT-proBNP, and other laboratory tests. Echocardiography should be performed in all patients as soon as possible (unless recently done and the result is available).
The initial clinical assessment should include evaluation of pre-load, after-load, and the presence of mitral regurgitation (MR) and other complicating disorders (including valvular complications, arrhythmia, and concomitant co-morbidities such as infection, diabetes mellitus, respiratory, or renal diseases). Acute coronary syndromes are a frequent cause of AHF and coronary angiography is often required.
Following initial assessment, an intravenous line should be inserted, and physical signs, ECG and SPO2 should be monitored. An arterial line should be inserted when needed.
The initial treatment of AHF consists of:
Oxygenation with face-mask or by CPAP (SPO2 target of 94–96%). Vasodilatation by nitrate or nitroprusside. Diuretic therapy by furosemide or other loop diuretic (initially intravenous bolus followed by continuous intravenous infusion, when needed) . Morphine for relief of physical and psychological distress and to improve haemodynamics . Intravenous fluids should be given if the clinical condition is pre-load-dependent and there are signs of low filling pressure.
This may require testing the response to an aliquot of fluid. . Other complicating metabolic and organ-specific conditions should be treated on their own merits. Patients with acute coronary syndrome or other complicated cardiac disorders should undergo cardiac catheterization and angiography, with a view to invasive intervention including surgery. Further specific therapies should be administered based on the clinical and haemodynamic characteristics of the patient who does not respond to initial treatment. This may include the use of inotropic agents or a calcium sensitizer for severe decompensated heart failure, or inotropic agents for cardiogenic shock.
The aim of therapy of AHF is to correct hypoxia and increase cardiac output, renal perfusion, sodium excretion, and urine output. Ultrafiltration or dialysis may be prescribed for refractory heart failure.
Patients with refractory AHF or end-stage heart failure should be considered for further support, where indicated including: intra-aortic balloon pump, artificial mechanical ventilation, or circulatory assist devices as a temporary measure, or as a ‘bridge’ to heart transplantation. The patient with AHF may recover extremely well, depending on the aetiology and the underlying pathophysiology. Prolonged treatment on the ward and expert care are required.