Akut Egzacerb Hron Si

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Acute exacerbation ofcongestive heart failure

HighlightsSummary

Overview

Basics

Definition

Epidemiology

Aetiology

Pathophysiology

Classification

Prevention

Primary

Screening

Secondary

DiagnosisHistory & examination

Tests

Differential

Step-by-step

Criteria

Guidelines

Case historyTreatment

Details

Step-by-step

Emerging
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Guidelines

Evidence

Follow Up

Recommendations

Complications

Prognosis

Resources

References

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History & exam

Key factors presence of risk factors (previous cardiovascular

disease, age >70 years) dyspnoea pulmonary crepitations peripheral oedema cool peripheries chest pain
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third heart sound (S3)

Other diagnostic factors

fatigue and weakness hypotension tachycardia elevated jugular venous pressure displaced apex beat (point of maximal impulse) dullness to percussion and decreased air entry in lung

bases wheezing palpitations cough fever syncope murmur ascites hepatomegaly central cyanosis

History & exam details

Diagnostic tests

1st tests to order ECG CXR Hb TFT troponin B-type natriuretic peptide (BNP)
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Tests to consider echocardiography cardiac catheterisation endomyocardial biopsy

Diagnostic tests details

Treatment details

Acute

haemodynamically stable

oxygen therapy morphine loop diuretics vasodilators supportive care ventilation inadequate response to loop diureticso non-loop diuretics due to cardiac ischaemiao aspirin revascularisation due to valvular diseaseo nitroprusside due to acute right heart failureo treatment of underlying cause due to acute myocarditiso supportive care or immunosuppressant therapy inadequate response to combination diureticso ultrafiltration

hypotensive (systolic BP


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oxygen therapy inotropes supportive care ventilation intra-aortic balloon pump left ventricular assist device (LVAD) due to cardiac ischaemiao aspirin revascularisation due to valve stenosiso percutaneous valvotomy

hypertensive crisis oxygen therapy IV beta-blockers and glyceryl trinitrate nitroprusside supportive care ventilation

Ongoing

acute episode stabilised: LVEF 100 mmHg

ACE inhibitor or angiotensin-II receptor antagonist beta-blocker aldosterone receptor antagonist vasodilators diuretics supportive care


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acute episode stabilised: LVEF


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DefinitionAcute congestive heart failure (CHF) is the rapid onset of symptoms andsigns due to abnormal cardiac function. It may be due to cardiac or extra-cardiac causes and results in reduced cardiac output, tissue hypoperfusion,

increased pulmonary capillary wedge pressure, and tissue congestion.[1]EpidemiologyBoth the incidence and prevalence of heart failure increase with age.[3] Inthe UK there were 60,480 cases of CHF in the 1-year period between 2006and 2007, with just more than 42,000 cases occurring in people over the ageof 75 years. [NHS. Hospital episode statistics] (external link) Studies of heartfailure in the US and Europe found that the annual incidence in people under65 years of age is 1/1000 for men and 0.4/1000 for women. Over 65 years ofage, the annual incidence is 11/1000 for men and 5/1000 for women. Under65 years of age, the prevalence of heart failure is 1/1000 for men and 1/1000for women; over age 65 years the prevalence is 40/1000 for men and30/1000 for women.[3]Heart failure is the most common indication for hospitalisation in the US, andacute decompensated heart failure is the most common cause forhospitalisation among patients over 65 years.[4]The prevalence of heart failure in the US in 2004 was an estimated 5.2 millionpeople. It has significant public health implications and the estimated cost ofheart failure in the US is $33.2 billion for the year 2007. The incidence ofheart failure is around 10/1000 people over 65 years per year.[5] In the US,the mean age of people with heart failure is 74 years, with 52% being womenand mostly white people affected (73% to 78%).[6] [7] The average age ofpeople with heart failure in studies conducted in Europe is also older than 70years, with slight predominance of men.[4]Heart failure is a global epidemic with a prevalence ranging from 11,000 to19,000 per million population among other countries.[8]

AetiologyCauses and precipitating factors in acute CHF are:[1]

Decompensation of pre-existing chronic heart failure

Acute coronary syndrome
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Hypertensive crisis

Acute arrhythmia

Valvular regurgitation

Severe aortic valve stenosis

Acute severe myocarditis

Cardiac tamponade

Aortic dissection

Post-partum cardiomyopathy

Non-cardiovascular precipitating factors

o Lack of compliance with medical treatment

o Volume overload

o Infections

o

Severe brain insult

o After major surgery

o Reduction of renal function


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o Asthma

o Drug abuse

o Phaeochromocytoma

High output syndromes

o Septicaemia

o Thyrotoxic crisis

o Anaemia

o Shunt syndromes.

The most common concurrent conditions present in patients with acute CHFare CAD, HTN, DM, atrial fibrillation, and renal insufficiency.[4] [9]

Causes of right heart failure include:[10] Secondary to LV failure

Secondary to pulmonary arterial hypertension

Secondary to right ventricle (RV) myopathic process

RV infarction

Arrythmogenic RV cardiomyopathy

Restrictive cardiomyopathy
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Pericardial disease

Right-sided valvular disease

Congenital heart disease.

PathophysiologyDuring an episode of acute CHF, the majority of patients will have evidenceof volume overload with pulmonary and/or venous congestion.Haemodynamic measurements in these cases usually show increased right-and left-sided ventricular filling pressures with depressed cardiac index and

cardiac output. However, if there is associated infection, the cardiac outputmay be normal or, in some cases, increased.

Activation of the sympathetic nervous system causes tachycardia, increasedmyocardial contractility, increased myocardial oxygen consumption,peripheral vasoconstriction, and activation of renin-angiotensin system withsalt and water retention. There is also activation of vasoconstrictorneurohormones, which leads to sodium and fluid retention, increasedmyocardial wall stress, and decreased renal perfusion.[11]

If the condition is not treated effectively, the myocardium becomes unable tomaintain a cardiac output sufficient to meet the demands of the peripheralcirculation. In order for patients with acute CHF to respond quickly totreatment, the increased myocardial stress must be reversed; for example,correction of acute severe HTN. This is particularly important in acute CHFcaused by ischaemia, as a dysfunctional myocardium can return to normalwhen appropriately treated.

ClassificationClinical presentations[1]

Acute CHF has been classified by the European Society of Cardiology intofollowing clinical groups:

1. Acute decompensated heart failure (ADHF)
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De novo or as decompensation of chronic CHF withsigns and symptoms of ADHF, which are mild and do notfulfil criteria for cardiogenic shock, pulmonary oedema, orhypertensive crisis.

2. Hypertensive acute CHF

Signs and symptoms of heart failure are accompaniedby high blood pressure (BP) and relatively preserved leftventricular (LV) function, with a CXR compatible with acutepulmonary oedema.

3. Pulmonary oedema (verified by CXR)View imageView image

Severe respiratory distress with associated crackles onlung examination, orthopnoea, and reduced oxygensaturation, usually below 90% on room air before treatment.

4. Cardiogenic shock

Defined as evidence of tissue hypoperfusion induced byheart failure after correction of preload.

Usually characterised by reduced BP (systolic BP 30 mmHg)and/or low urine output (60 bpm, with or without evidence of organ congestion.

There is a continuum from low cardiac output syndrometo cardiogenic shock.

5. High output failure
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Characterised by high cardiac output, usually with highheart rate (caused by arrhythmias, thyrotoxicosis, anaemia,Paget's disease, iatrogenic, or other mechanisms), withwarm peripheries, pulmonary congestion, and, sometimes,

with low BP such as in septic shock.

6. Right heart failure

Characterised by low output syndrome with increasedjugular venous pressure, increased liver size, andhypotension.

Clinical classification of acute heart failure (AHF)[2]For simplification these patients can be classified into 3 main groups:

1. Hypertensive AHF (acute de novo heart failure or vascular failure)

Symptoms develop rapidly against a background of

hypertension (HTN) with increased sympathetic tone andneurohormonal activations.

Left ventricular ejection fraction (LVEF) is usuallypreserved and there are clinical and radiological findings ofpulmonary congestion, usually without signs of systemiccongestion; for example, peripheral oedema.

Response to therapy is rapid.

2. Normotensive AHF (acutely decompensated chronic heart failure)

History of progressive worsening of chronic heart failure.
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BP is usually normal and symptoms and signs developgradually with both systemic and pulmonary congestion.

LVEF is usually reduced.

3. Hypotensive AHF

Presents with symptoms and signs of hypotension,organ hypoperfusion, and cardiogenic shock.

Types of heart failure

Systolic

Associated with LV dysfunction and characterised bycardiomegaly, third heart sound, and volume overload withpulmonary congestion. LVEF is decreased.

Diastolic

Typically associated with normal cardiac size,hypertension, pulmonary congestion, and a fourth heartsound. LVEF is preserved.

Primary preventionAggressive control and treatment of risk factors should be considered in order

to prevent acute heart failure: CAD is managed with aspirin, beta-blockers,statins, and ACE inhibitors.

Optimising treatment of HTN, smoking cessation, and lipid control providessubstantial benefit in patients with CAD.


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Optional control of HTN may require more than one antihypertensivemedication.

In asymptomatic patients with reduced LVEF, ACE inhibitors arecardioprotective and reduce further decline in LVEF.[19] Beta-blockers may

also be considered in this group of patients.All patients with diabetes mellitus (DM), in addition to metabolic control, needaggressive control of lipids, BP (target


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Salt intake restricted: 1 teaspoon of salt equals 2.2 g ofsodium. Therefore, patients are advised not to exceed 1teaspoon of salt a day. They should lower salt intake asmuch as possible, ideally to 65 mmols/day of sodium

(corresponding to 1.5 g/day of sodium).

Alcohol intake limited to 2 drinks a day for men and 1drink a day or less for woman.

Importance of continuing medication as prescribed bydoctor should be stressed.

Weight should be checked daily.

If patients notice more than 0.9 kg (>2 pounds) weight gain in 24 hours, 2days in a row, or develop symptoms of shortness of breath, chest pain,palpitations, increased tiredness, dizziness. or lightheadedness, or increasingswelling of the legs or abdomen, they should seek medical attention.

Complications

Complicationhide all

arrhythmias

see our comprehensive coverage of Overview of dysrhythAcute CHF is frequently precipitated by arrhythmias, in pa

cause arrhythmias.[71] [72]

complications of glyceryl trinitrate

Commonly causes headache and hypotension. The headseverity and either resolves or diminishes in intensity with
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hypotension occurs then the infusion rate should be decreinfusion should be discontinued and re-started when patie

complications of treatment: nesiritide

Causes headache and hypotension. If hypotension occursdecreased. If hypotension persists than the infusion shoupatient is haemodynamically stable.

complications of treatment: diureticsOver-diuresis leads to worsening of renal function, hypoteactivation of neurohormones including renin-angiotensin smay potentiate the toxicity of other agents like digoxin, eitdecreasing the glomerular filtration.

In cases of worsening renal impairment due to over-diures

decreased. In case of severe renal impairment the diureticassessed daily, with re-introduction of diuretic at lower do

complications of treatment: inotropes

Dobutamine and milrinone can cause arrhythmias and wo

The occurrence of sustained arrhythmias should lead to dmedications are absolutely needed, concomitant use of amthere are no large-scale data on the use of anti-arrhythmicsymptomatic coronary ischaemia, these infusions should


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PrognosisIn hospital, mortality ranges from 2% to 20% depending on clinical factorsfound on admission.[69] Predictors of adverse outcomes include:hypotension, renal dysfunction, older age, male sex, ischaemic CHF,

previous CHF, respiratory rate on admission >30/minute, anaemia,hyponatraemia, elevated troponin, elevated B-type natriuretic peptide (BNP),and other comorbidities such as cancer.[70]

Case history #1A 70-year-old woman complains of increasing exertional dyspnoea for thelast 2 days and now has dyspnoea at rest. She has a history of hypertensionfor the last 5 years and a 35 pack-year smoking history, but no otherestablished illnesses. Current medications are hydrochlorothiazide daily forthe last 3 years. She has been prescribed lisinopril but failed to fill theprescription. On examination her BP is 190/90 mmHg, heart rate 104 bpm.There is an audible S4 and the jugular venous pressure (JVP) is elevated 2cm above normal. Lung examination reveals fine bibasal crepitations. Thereis no ankle oedema.

Case history #2A 73-year-old woman presents to the emergency department having

collapsed. She is breathless and finding it difficult to talk in full sentences. Onexamination she is centrally cyanosed with cool extremities. Her pulse is 110bpm and systolic BP only just recordable at 80 mmHg. Jugular venouspressure (JVP) is elevated 3 cm above normal and the cardiac apex beat isdisplaced. Respiratory rate is increased and she has widespread cracklesand wheezes on chest examination.

Other presentations

Patients may present with predominant symptoms of the underlying conditionsuch as chest pain with acute MI, syncope with significant valvular stenosis,palpitations with arrhythmias, and viral prodrome with myocarditis.
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Differential diagnosis

Condition

Differentiating

signs/symptoms Differentiating

Pneumonia Fever, cough,

productivesputum.

Focal signs ofconsolidation -increased vocalfremitus andbronchialbreathing.

WCC: ele

Blood cul

CXR: con

Pulmonary embolism Haemoptysis and

sharp, pleuriticchest pain.

Risk factors ofthromboembolism (TE) includepersonal historyof TE, familyhistory, recenttrauma,prolongedimmobilisation,

CT pulmo
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smoker, or OCPuse.

Asthma Wheezing on

physicalexamination.

Reduced

Spirometr

Interstitial lung disease Progressively

increasingdyspnoea.

Oxygendesaturation withexercise.

Fine bibasalcrepitations withno other signs ofheart failure.

CXR: retic

High-resohoneycom

Spirometr

Adult respiratory distress

syndrome

Severe hypoxia,

fine crepitations.

CXR: diffu

Pulmonar
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History & examinationKey diagnostic factorshide allpresence of risk factors (previous cardiovascular

disease, age >70 years) (common)

Key risk factors include age over 70 years, previouscardiovascular disease, diabetes, and poor compliancewith medication for chronic CHF.

dyspnoea (common)

Predominant symptom and is present in the majority ofpatients with acute CHF.[9]

pulmonary crepitations (common)

Key finding on chest examination.[9]peripheral oedema (common)

Present in the majority of patients (around 65% ofcases).[6] [9]

cool peripheries (common)

is a key diagnostic factorchest pain (uncommon)

If underlying cardiac ischaemia.third heart sound (S3) (uncommon)

is a key diagnostic factor

Other diagnostic factorshide allfatigue and weakness (common)

is a diagnostic factorhypotension (common) is a diagnostic factor

tachycardia (common)

Due to activation of the sympathetic nervous system orunderlying arrhythmia.
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elevated jugular venous pressure (common)

is a diagnostic factordisplaced apex beat (point of maximal

impulse) (common)

is a diagnostic factordullness to percussion and decreased air entry in lung

bases(common)

Suggestive of pleural effusion.wheezing (common)

Suggests cardiac asthma.palpitations (uncommon)

If underlying arrhythmia.cough (uncommon)

Due to pulmonary congestion.fever(uncommon)

Suggestive of precipitating underlying infection.syncope (uncommon)

Suggestive of underlying cause, such as significant

aortic stenosis or pulmonary embolism.murmur(uncommon)

Both significant stenotic and regurgitate lesions canlead to heart failure.

ascites (uncommon)

is a diagnostic factorhepatomegaly (uncommon)

is a diagnostic factorcentral cyanosis (uncommon)

is a diagnostic factor


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Risk factorshide all

Strong

age >70 years A typical patient with acute heart failure is older than

70 years.[6]prior episode of congestive heart failure

In patients hospitalised for acute CHF, around 75%have a history of prior heart failure.[6]

coronary artery disease

CAD accounts for around 50% of all patients withacute HF.[6] [7] [12] [13] Chronic myocardialischaemia results in myocardial damage withprogressive decline in left ventricular (LV) systolicfunction. Subendocardial ischaemia also causesincrease in left ventricular end diastolic pressure(LVEDP) leading to pulmonary oedema in the

presence of normal LV systolic function. Acute coronary ischaemia can lead to acute CHF

either due to pump failure or papillary muscledestruction/rupture. In the case of pump failure, the LVfunction is depressed, but in cases of heart failureassociated with papillary muscle rupture, themeasured LV function may appear preserved.

hypertension A history of HTN is present in 72% of patients in the

US and 60% of patients from Europe.[6] [12] [13] HTN predisposes to the development of heart failure

by increasing the after-load on the ventricles, which
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induces LVH, which in turn leads to LV dysfunction, anincreased risk of MI, and significant arrhythmias.

In patients with non-compliant ventricles, an abrupt orsignificant increase in BP increases the LVEDP,

precipitating acute CHF.valvular heart disease

About 23% of patients in the US and 34% in Europehave valvular disease as an associatedcondition.[6] [13]Both significant stenotic andregurgitate lesions can lead to heart failure.

Although rheumatic valvular disease is now rarely

found in western countries, calcific valvular heartdisease, in particular aortic stenosis, is commonlyencountered.

In patients with significant valvular disease, the heartfailure will not improve until the underlying valvulardisease has been corrected.

pericardial disease

A large pericardial effusion can present with symptomsor signs of acute CHF.

Pericardial constriction, such as tuberculosispericarditis or the effects of radiotherapy, can alsopresent with acute CHF.

myocarditis

There are many causes of myocarditis, of which a viral

aetiology appears to be the most common. There isusually a prodrome of a non-specific illnesscharacterised by fatigue, mild dyspnoea, and myalgias.

atrial fibrillation

Present in 31% of cases.[6]
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diabetes mellitus

Related directly to ischaemia and renal failure.non-compliance with medications

Precipitating factor in patients with chronic CHF.

Weak

excessive salt intake

Present in 22% of cases.[14]excessive catecholamine stimulation

Can be caused by phaeochromocytoma orsubarachnoid haemorrhage.[15]

abnormal thyroid function

Both hypothyroidism and thyrotoxicosis can beassociated with heart failure.[16] [17]

excessive alcohol intake

Excessive drinking is associated with heart failure (>3drinks/day).[18]

Diagnostic tests1st tests to orderhide all

Test

ECG

The ECG analysis in acute CHF shows atrial fibrillation in 26% of the cases.[6]ECG abnormality is found in almost all cases of heart failualternate diagnosis should be considered.[31] View imag

CXR

Pulmonary congestion on CXR is present in up to 76% of
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image

Hb

Suggests anaemia as a precipitating cause.

TFT

Hypo- or hyperthyroidism can cause acute CHF.

troponin

Elevated in acute cardiac ischaemia.

Also elevated in over 50% of cases of acute CHF without

B-type natriuretic peptide (BNP)

If above 500 nanograms/L (>500 picograms/mL), dyspnoe

If below 100 nanograms/L (


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Left ventricular ejection fraction (LVEF) 40% is transient systolic dysfunction or diagnosticPreserved LVEF (45%) is observed in 34% of patients wGuidelines from the European Association of Echocardiognormal. An LVEF of 45% to 54% is mildly abnormal, LVEFLVEF of


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chronic CHF such as dietary indiscretion with excessive salt intake, non-compliance with medications, and excessive alcohol or drug intake.

Symptoms

Heart failure presents with dyspnoea, decreased exercise tolerance, swellingof the legs, fatigue, and generalised weakness. Sometimes the patient maypresent with predominant symptoms of the underlying condition, such aschest pain, syncope, palpitations, or viral prodrome.

SignsCommon signs include central cyanosis, tachycardia, elevated jugular venouspressure (JVP), displaced apex beat, S3, crepitations or pleural effusion,

hepatomegaly, ascites, and oedema. The presence of these signs dependsupon the duration, acuity, and the underlying cause of heart failure. Patientswith end-stage heart failure may exhibit most of these clinical signs, whereasthose in the early phase of the illness may have minimal signs.

Patients with acute CHF can be classified clinically into 4 haemodynamicprofiles.[24] These profiles, which are based on haemodynamic principles ofpresence or absence of elevated filling pressure (wet or dry) and perfusionthat is adequate or critically limited (warm or cold), include:

Warm and dry

Warm and wet

Cold and dry

Cold and wet.

Patients with pulmonary oedema present with severe respiratory distress withreduced oxygen saturation (usually 60 bpm and/or low urine output (


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without evidence of organ congestion, are considered to be in cardiogenicshock.

Immediate investigations

An ECG and CXR should be performed immediately in all patients withsuspected acute CHF. ECG findings are commonly related to the underlyingpathologies and include presence of Q waves, ST-T changes, left ventricularhypertrophy (LVH), left bundle branch block, and atrial fibrillation.View image

CXR may show cardiac enlargement (cardiothoracic ratio >50%); however,there is poor correlation between the cardiothoracic ratio (CTR) and presenceof heart failure, as the heart size may be normal in patients with diastolicdysfunction, acute valvular regurgitation as part of infective endocarditis, oracute MI. An enlarged CTR may also be seen in the absence of heart failure

(e.g., pericardial effusion and LVH).

Evaluation of the lung fields will show signs of pulmonary congestion, initiallyin the upper zones, then in the horizontal fissures followed by pulmonaryoedema and pleural effusion.View imageView image The x-ray findings haveto be taken in the context of clinical picture, as pulmonary infiltrates andcongestion, in some cases, may be due to non-cardiac cause such as ARDSor alveolar haemorrhage.

CXRs rarely may show pericardial calcification, prosthetic valves, or valvularcalcification. In these situations, it is helpful in identifying the possibleunderlying aetiology for heart failure.

The following blood tests should be requested when patients present withsuspected acute CHF:[22]

Hb: may identify anaemia as a contributing factor.

TFTs: both hypothyroidism and hyperthyroidism cancause heart failure.

Cardiac enzymes: >50% of patients with cardiogenicpulmonary oedema (but without evidence for MI) haveelevated troponin T levels.[25] Elevated troponin T levels in
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patients with acute CHF may reflect subendocardialischaemia due to elevated left ventricular end diastolicpressure. In patients with acute cardiogenic pulmonaryoedema, a troponin T level of 0.1 g/L (0.1 ng/mL) is a

powerful independent predictor and is associated with poorlong-term survival.[25]

BNP: measurement of serum BNP level in patients withsymptoms of heart failure is now routinely carried out in mostcentres. The addition of BNP or N-terminal pro-brainnatriuretic peptide (NT-proBNP) levels to clinical assessmentsignificantly enhances the accuracy of diagnosis and

effectiveness of acute management.[26] [27] BNP is alsohelpful in differentiating a cardiac from a pulmonary cause ofdyspnoea.[28]An elevated BNP level is a predictor of in-hospital mortality in patients with acute decompensatedheart failure.[29]However, an elevated BNP level shouldonly be taken in the context of clinical picture as it may beincreased in a variety of other condition, such as atrial

fibrillation, pulmonary embolism, or sepsis.[30]

Subsequent investigationsEchocardiogram is an integral part of the evaluation in a patient with acuteCHF and should be performed as soon as possible to presentation. It isrequired to assess chamber size, ventricular function (systolic and diastolic),ventricular wall thickness, valvular function, and the pericardium.ViewimageView image

Cardiac catheterisation is needed in cases where significant CAD is thoughtto be the contributing factor, and is also indicated in cases where the causeof acute CHF can not be determined from other tests.

Endomyocardial biopsy is not recommended for routine evaluation of acuteCHF, but is indicated in patients whose clinical findings suggest acutemyocarditis.
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Click to view diagnostic guideline references. Diagnosticcriteria

Framingham criteria for CHF[33]The Framingham criteria are the most widely accepted clinical criteria fordiagnosing heart failure. For establishing a definite diagnosis of CHF, 2 majorcriteria or 1 major and 2 minor criteria must be present.

Major criteria are:

Paroxysmal nocturnal dyspnoea or orthopnoea

Neck-vein distention

Rales

Cardiomegaly

Acute pulmonary oedema

S3 gallop

Increased venous pressure >16 cm of water

Circulation time 25 seconds or longer

Hepatojugular reflux.

Minor criteria are:

Ankle oedema
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Night cough

Dyspnoea on exertion

Hepatomegaly

Pleural effusion

Vital capacity reduced one third from maximum

Tachycardia (120 bpm).

Major or minor criteria are:

Weight loss of 4.5 kg or more in 5 days in response totreatment.

New York Heart Association (NYHA) clinical classification

of heart failure[34] Class I: asymptomatic

Class II: mild symptoms with moderate exertion

Class III: symptoms with minimal activity

Class IV: symptoms at rest.

Treatment Options
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Patient group

Treatment line Treatmenthide all


1st oxygen therapy

Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue

oxygenation.

adjunct

[?]morphine

Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the

patient is restless andsignificantlydyspnoeic.[1]

Primary Options

morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired

plus

[?]loop diuretics

Indicated in patients witha systolic BP >85mmHg.[1]
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Patient group



1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics

http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-70&optionId=expsec-637863&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-71&optionId=expsec-637863&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-39http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-56http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-39http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-56http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-39http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-56http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-57http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-57http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-57http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-69&optionId=expsec-637863&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-70&optionId=expsec-637863&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-71&optionId=expsec-637863&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-39http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-56http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-57


34/78

Patient group



1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics

http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-40http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-72&optionId=expsec-637866&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-72&optionId=expsec-637866&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-73&optionId=expsec-637866&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-40http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-58http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-59http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-72&optionId=expsec-637866&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-73&optionId=expsec-637866&dd=MARTINDALE


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Patient group



1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics



36/78

Patient group



1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics

http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-37&optionId=expsec-637890&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-37&optionId=expsec-637890&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-37&optionId=expsec-637890&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-37&optionId=expsec-637890&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-37&optionId=expsec-637890&dd=MARTINDALE


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Patient group



1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics

http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-38&optionId=expsec-637890&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-39&optionId=expsec-637890&dd=MARTINDALE


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Patient group



1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics

http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-49http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-49http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-49http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-49http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-49http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-49http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-49http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-49http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-49http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-41&optionId=expsec-637884&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-49


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Patient group



1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics



42/78

Patient group



1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics



43/78

Patient group



1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics

http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-43http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-43http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-43http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-43http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-43http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-43http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-43http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-60http://bestpractice.bmj.com/best-practice/monograph/62/treatment/evidence/score/5.html


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Patient group



1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics

http://bestpractice.bmj.com/best-practice/monograph/62/treatment/evidence/score/5.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-45http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-46http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-45http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-46http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-47http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-45http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-46http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-47http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-45http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-46http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-47http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-45http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-46http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-47http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-45http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-46http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-45http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-45http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-60http://bestpractice.bmj.com/best-practice/monograph/62/treatment/evidence/score/5.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-45http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-46http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-47


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Patient group



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oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics

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Patient group



1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics

http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-76&optionId=expsec-637896&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-77&optionId=expsec-637896&dd=MARTINDALE


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Patient group



1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics

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Patient group



1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics

http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53


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Patient group



1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics

http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-42&optionId=expsec-637926&dd=MARTINDALE


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Patient group



1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics

http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-14&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-14&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-15&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-14&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-15&optionId=expsec-15&dd=MARTINDALE


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Patient group



1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics

http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-16&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-16&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-1&optionId=expsec-16&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-1&optionId=expsec-16&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-1&optionId=expsec-16&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-1&optionId=expsec-16&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-16&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-1&optionId=expsec-16&dd=MARTINDALE


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1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics



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1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics



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1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics



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1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics



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Patient group



1st oxygen therapy


oxygenation.

adjunct

[?]morphine



Primary Options


plus

[?]loop diuretics

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