Sepsis With Preexisting Heart Failure: Management of Confounding Clinical Features

Abstract

Preexisting heart failure (HF) in patients with sepsis is associated with worse clinical outcomes. Core sepsis management includes aggressive volume resuscitation followed by vasopressors (and potentially inotropes) if fluid is inadequate to restore perfusion; however, large fluid boluses and vasoactive agents are concerning amid the cardiac dysfunction of HF. This review summarizes evidence regarding the influence of HF on sepsis clinical outcomes, pathophysiologic concerns, resuscitation targets, hemodynamic interventions, and adjunct management (ie, antiarrhythmics, positive pressure ventilatory support, and renal replacement therapy) in patients with sepsis and preexisting HF. Patients with sepsis and preexisting HF receive less fluid during resuscitation; however, evidence suggests traditional fluid resuscitation targets do not increase the risk of adverse events in HF patients with sepsis and likely improve outcomes. Norepinephrine remains the most well-supported vasopressor for patients with sepsis with preexisting HF, while dopamine may induce more cardiac adverse events. Dobutamine should be used cautiously given its generally detrimental effects but may have an application when combined with norepinephrine in patients with low cardiac output. Management of chronic HF medications warrants careful consideration for continuation or discontinuation upon development of sepsis, and β-blockers may be appropriate to continue in the absence of acute hemodynamic decompensation. Optimal management of atrial fibrillation may include β-blockers after acute hemodynamic stabilization as they have also shown independent benefits in sepsis. Positive pressure ventilatory support and renal replacement must be carefully monitored for effects on cardiac function when HF is present.

Keywords: antiarrhythmics; fluids; heart failure; inotropes; resuscitation; sepsis; septic shock; vasopressors.

Figure 1.

Depiction of proposed optimal interventions for septic shock with preexisting HF in the first 24 hours of management. Fluid resuscitation should consist of 30 mL/kg administered in the first 3 hours unless obvious findings indicating a high risk of harm are present. Monitoring should include careful physical assessment and indices of volume resuscitation status. Administering less than 3 L of fluid in patients with HFrEF over the first 6 hours provides a reasonable conservative goal; however, fluid should not be withheld when multiple indices and clinical status indicate it would be highly beneficial. Preferred vasopressors agents are NE, vasopressin, and possibly epinephrine, while dopamine should be avoided when possible. Inotropes are not universally recommended, but dobutamine may be considered in patients with persistently low CO and low EF. Milrinone may be more efficacious in patients currently receiving a BB. If AF is present, esmolol and diltiazem may be used in the short term, and amiodarone may be more hemodynamically favorable in whom even small changes in blood pressure are concerning. Digoxin should not be used routinely for acute AF management. Septic tachycardia from adrenergic overstimulation and increased cardiac workload may be mitigated by avoiding inotropic stimulation and epinephrine, and by esmolol infusion started 24 hours after hemodynamic optimization, or continuation of home BB. AF, atrial fibrillation; BB, β-blocker; CO, cardiac output; EF, ejection fraction; HF, heart failure; HFrEF, heart failure reduced ejection fraction; NE, norepinephrine