Key messages

• Management is aimed at improvement of forward flow with restoration/maintenance of adequate organ perfusion and perfusion pressures, and relief of symptoms.

• The oxygen supply-demand balance should be optimized within both the myocardium and the body as a whole. Therapy should be aimed at both decreasing demand and increasing supply.

• Considerable improvement in outcome can be obtained with an aggressive regimen of myocardial revascularization and resting. Introduction

The 5-year mortality from heart failure is approximately 50 per cent and directly correlates with both the severity of symptoms and exercise capacity. However, acute cardiogenic shock generally carries a hospital mortality of the order of 80 to 90 per cent, although recent data suggest considerable improvement with an aggressive regimen of myocardial revascularization and resting.

The fundamental therapeutic principles of heart failure management comprise improvement of forward flow with restoration/maintenance of adequate organ perfusion, and relief of symptoms. These symptoms arise as a consequence of a cardiac output/oxygen delivery that is insufficient to meet the body's needs, raised pulmonary venous pressures, and the body's attempt to compensate for low flow by peripheral vasoconstriction.

Appropriate management requires sound appreciation of the underlying pathophysiology, awareness of the actions and potential side-effects of each therapeutic intervention, and a level of monitoring and investigation sophisticated enough to assess disease severity and the effectiveness (or otherwise) of any treatment being given. Where possible, consideration of previous comorbid factors and chronic symptomatology should guide how aggressive intervention should be. However, these must be based on documented fact rather than hearsay or supposition. The patient should always be given the benefit of the doubt.

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