Heart failure

Heart failure occurs in about 20 to 30 per cent of all acute myocardial infarction and is associated with a much poorer long-term outlook. As indicated above, it is useful to use intravenous nitrates initially to reduce afterload. However, these rapidly become less effective because of tolerance. Angiotensin-converting enzyme inhibitors should be started cautiously, but only in patients with a systolic blood pressure above 100 mmHg. Diuretics, particularly intravenous furosemide (frusemide) or bumetanide are commonly given, but the potassium level and intravascular volume depletion should be watched carefully and avoided.

An urgent echocardiogram is essential in all cases to exclude surgical causes such as papillary muscle or chordal rupture, cardiac rupture, or cardiac tamponade. Even in the absence of these complications, an echocardiogram will reveal the extent of infarction.

A dobutamine stress echocardiogram may reveal the presence of viable but ischemic myocardium (hibernating) and indicate the need for urgent catheterization and reperfusion by PTCA or surgery. Other treatable causes of heart failure such as anemia or fluid overload should also be considered carefully before treatment which is only symptomatic is given.

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