wikidoc - User contributions [en]

Pyomyositis

2014-05-19T20:16:53Z

Ayokunle Olubaniyi: /* Medical Therapy */

__NOTOC__
{{Gas gangrene}}
{{CMG}}; {{AE}}

==Overview==
'''Pyomyositis''', also known as '''tropical pyomyositis''' or '''myositis tropicans''' is a [[bacteria]]l [[infection]] of the [[skeletal muscle]]s which results in a [[pus]]-filled [[abscess]]. Pyomyositis is more common in [[tropical]] areas but can also occur in the [[temperate zone]]s. Pyomyositis is most often caused by the bacterium ''[[Staphylococcus aureus]]''.<ref name="Chauhan-2004">{{Cite journal | last1 = Chauhan | first1 = S. | last2 = Jain | first2 = S. | last3 = Varma | first3 = S. | last4 = Chauhan | first4 = SS. | title = Tropical pyomyositis (myositis tropicans): current perspective. | journal = Postgrad Med J | volume = 80 | issue = 943 | pages = 267-70 | month = May | year = 2004 | doi = | PMID = 15138315 }}</ref> The infection can affect any skeletal muscle, but most often infects the large muscle groups such as the [[quadriceps]] or [[gluteal muscles]]. In tropical regions, the infection often follows minor trauma, while in temperate zones the infection typically occurs in people with [[immunocompromised|immune deficiencies]]. The abscess within the muscle must be drained [[surgery|surgically]] and [[antibiotics]] given to fully clear the infection.

==Medical Therapy==
{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Pyomyositis}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen (For MSSA)
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Nafcillin]] 1–2 g IV q4h''''' OR ▸ '''''[[Oxacillin]] 1–2 g IV q4h ''''' OR ▸ '''''[[Cefazolin]] 1 g IV q8h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen (For MRSA)
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 1 gm IV q12h'''''
|}
|}

==References==
{{reflist|2}}

[[Category:Disease]]
[[Category:Infectious disease]]
[[Category:Wikinfect]]
[[Category:Emergency medicine]]
[[Category:Primary care]]

{{WH}}
{{WS}}

Gas gangrene medical therapy

2014-05-19T19:31:50Z

Ayokunle Olubaniyi: /* Overview */

__NOTOC__
{{Gas gangrene}}
{{CMG}}; {{AE}}

==Overview==
Any significantly massive infection is a medical emergency. In cases of gangrene, the infection is so severe by the time that a diagnosis is made that countering the bacterial load is impossible even with the strongest available [[antibiotic]]s, for example [[gentamycin]] and [[vancomycin]]. [[Antibiotic]]s alone are not effective because they don't penetrate [[ischemic]] [[muscle]]s enough to be effective. There are two major reasons for this; current antibiotics only prevent replication of bacteria and the production of toxins continues in pre-existing bacteria. Also, the extent of injury caused by the infection may leave the muscle tissues so damaged that the body will never be able to replace the lost structures (including vasculature).

Currently, the use of [[penicillin G]] and [[clindamycin]] combination remains the most effective and preferred treatment.<ref name="Stevens-2005">{{Cite journal | last1 = Stevens | first1 = DL. | last2 = Bisno | first2 = AL. | last3 = Chambers | first3 = HF. | last4 = Everett | first4 = ED. | last5 = Dellinger | first5 = P. | last6 = Goldstein | first6 = EJ. | last7 = Gorbach | first7 = SL. | last8 = Hirschmann | first8 = JV. | last9 = Kaplan | first9 = EL. | title = Practice guidelines for the diagnosis and management of skin and soft-tissue infections. | journal = Clin Infect Dis | volume = 41 | issue = 10 | pages = 1373-406 | month = Nov | year = 2005 | doi = 10.1086/497143 | PMID = 16231249 }}</ref>

==Medical Therapy==

{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Gas Gangrene}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 600-900 mg IV q8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 2-4 million units q4–6h IV'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 2 gm IV q12h''''' OR ▸ '''''[[Erythromycin]] 1 gm q6h IV (not by bolus)'''''
|-
|}
|}

==References==
{{reflist|2}}

[[Category:Disease]]
[[Category:Infectious disease]]
[[Category:Emergency medicine]]
[[Category:Primary care]]

{{WH}}
{{WS}}

Gas gangrene medical therapy

2014-05-19T19:28:43Z

Ayokunle Olubaniyi:

__NOTOC__
{{Gas gangrene}}
{{CMG}}; {{AE}}

==Overview==
Any significantly massive infection is a medical emergency. In cases of gangrene, the infection is so severe by the time that a diagnosis is made that countering the bacterial load is impossible even with the strongest available [[antibiotic]]s, for example [[gentamycin]] and [[vancomycin]]. [[Antibiotic]]s alone are not effective because they don't penetrate [[ischemic]] [[muscle]]s enough to be effective. There are two major reasons for this; current antibiotics only prevent replication of bacteria and the production of toxins continues in pre-existing bacteria. Also, the extent of injury caused by the infection may leave the muscle tissues so damaged that the body will never be able to replace the lost structures (including vasculature).

Currently, the use of [[penicillin G]] and [[clindamycin]] combination remains the most effective and preferred treatment.<ref name="Stevens-2005">{{Cite journal | last1 = Stevens | first1 = DL. | last2 = Bisno | first2 = AL. | last3 = Chambers | first3 = HF. | last4 = Everett | first4 = ED. | last5 = Dellinger | first5 = P. | last6 = Goldstein | first6 = EJ. | last7 = Gorbach | first7 = SL. | last8 = Hirschmann | first8 = JV. | last9 = Kaplan | first9 = EL. | title = Practice guidelines for the diagnosis and management of skin and soft-tissue infections. | journal = Clin Infect Dis | volume = 41 | issue = 10 | pages = 1373-406 | month = Nov | year = 2005 | doi = 10.1086/497143 | PMID = 16231249 }}</ref> Alternative drugs such as [[vancomycin]], [[linezolid]], [[quinupristin dalfopristin|quinupristin/dalfopristin]], or [[daptomycin]] can be used in patients with severe [[Penicillin G benzathine adverse reactions|penicillin hypersensitivity]].

==Medical Therapy==

{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Gas Gangrene}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 600-900 mg IV q8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 2-4 million units q4–6h IV'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 2 gm IV q12h''''' OR ▸ '''''[[Erythromycin]] 1 gm q6h IV (not by bolus)'''''
|-
|}
|}

==References==
{{reflist|2}}

[[Category:Disease]]
[[Category:Infectious disease]]
[[Category:Emergency medicine]]
[[Category:Primary care]]

{{WH}}
{{WS}}

Gas gangrene medical therapy

2014-05-19T19:14:10Z

Ayokunle Olubaniyi:

__NOTOC__
{{Gas gangrene}}
{{CMG}}; {{AE}}

==Overview==
Any significantly massive infection is a medical emergency. In cases of gangrene, the infection is so severe by the time that a diagnosis is made that countering the bacterial load is impossible even with the strongest available [[antibiotic]]s, for example [[gentamycin]] and [[vancomycin]]. [[Antibiotic]]s alone are not effective because they don't penetrate [[ischemic]] [[muscle]]s enough to be effective. There are two major reasons for this; current antibiotics only prevent replication of bacteria and the production of toxins continues in pre-existing bacteria. Also, the extent of injury caused by the infection may leave the muscle tissues so damaged that the body will never be able to replace the lost structures (including vasculature).

Currently, the use of [[penicillin G]] and [[clindamycin]] combination remains the most effective and preferred treatment.<ref name="Stevens-2005">{{Cite journal | last1 = Stevens | first1 = DL. | last2 = Bisno | first2 = AL. | last3 = Chambers | first3 = HF. | last4 = Everett | first4 = ED. | last5 = Dellinger | first5 = P. | last6 = Goldstein | first6 = EJ. | last7 = Gorbach | first7 = SL. | last8 = Hirschmann | first8 = JV. | last9 = Kaplan | first9 = EL. | title = Practice guidelines for the diagnosis and management of skin and soft-tissue infections. | journal = Clin Infect Dis | volume = 41 | issue = 10 | pages = 1373-406 | month = Nov | year = 2005 | doi = 10.1086/497143 | PMID = 16231249 }}</ref> Alternative drugs such as [[vancomycin]], [[linezolid]], [[quinupristin dalfopristin|quinupristin/dalfopristin]], or [[daptomycin]] can be used in patients with severe [[Penicillin G benzathine adverse reactions|penicillin hypersensitivity]].

==Medical Therapy==

{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Gas Gangrene}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 600-900 mg IV q8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 2-4 million units q4–6h IV'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 2 gm IV q12h''''' OR ▸ '''''[[Erythromycin]] 1 gm q6h IV (not by bolus)'''''
|-
|}
|}

==References==
{{reflist|2}}

[[Category:Disease]]
[[Category:Infectious disease]]
[[Category:Wikinfect]]
[[Category:Emergency medicine]]
[[Category:Primary care]]

{{WH}}
{{WS}}

Pyomyositis

2014-05-19T19:13:42Z

Ayokunle Olubaniyi:

Gas gangrene medical therapy

2014-05-19T19:03:48Z

Ayokunle Olubaniyi: /* Overview */

__NOTOC__
{{Gas gangrene}}
{{CMG}}; {{AE}}

==Overview==
Any significantly massive infection is a medical emergency. In cases of gangrene, the infection is so severe by the time that a diagnosis is made that countering the bacterial load is impossible even with the strongest available [[antibiotic]]s, for example [[gentamycin]] and [[vancomycin]]. [[Antibiotic]]s alone are not effective because they don't penetrate [[ischemic]] [[muscle]]s enough to be effective. There are two major reasons for this; current antibiotics only prevent replication of bacteria and the production of toxins continues in pre-existing bacteria. Also, the extent of injury caused by the infection may leave the muscle tissues so damaged that the body will never be able to replace the lost structures (including vasculature).

Currently, the use of [[penicillin G]] and [[clindamycin]] combination remains the most effective and preferred treatment.<ref name="Stevens-2005">{{Cite journal | last1 = Stevens | first1 = DL. | last2 = Bisno | first2 = AL. | last3 = Chambers | first3 = HF. | last4 = Everett | first4 = ED. | last5 = Dellinger | first5 = P. | last6 = Goldstein | first6 = EJ. | last7 = Gorbach | first7 = SL. | last8 = Hirschmann | first8 = JV. | last9 = Kaplan | first9 = EL. | title = Practice guidelines for the diagnosis and management of skin and soft-tissue infections. | journal = Clin Infect Dis | volume = 41 | issue = 10 | pages = 1373-406 | month = Nov | year = 2005 | doi = 10.1086/497143 | PMID = 16231249 }}</ref> Alternative drugs such as [[vancomycin]], [[linezolid]], [[quinupristin dalfopristin|quinupristin/dalfopristin]], or [[daptomycin]] can be used in patients with severe [[Penicillin G benzathine adverse reactions|penicillin hypersensitivity]].

==Medical Therapy==

{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Gas Gangrene}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 600-900 mg IV q8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 2-4 million units q4–6h IV'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 2 gm IV q12h''''' OR ▸ '''''[[Erythromycin]] 1 gm q6h IV (not by bolus)'''''
|-
|}
|}

==References==
{{reflist|2}}

[[Category:Disease]]
[[Category:Surgery]]
[[Category:Pathology]]
[[Category:Infectious disease]]
[[Category:Needs content]]
[[Category:Bacterial diseases]]

{{WH}}
{{WS}}

Gas gangrene medical therapy

2014-05-19T19:02:42Z

Ayokunle Olubaniyi: /* Overview */

__NOTOC__
{{Gas gangrene}}
{{CMG}}; {{AE}}

==Overview==
Any significantly massive infection is a medical emergency. In cases of gangrene, the infection is so severe by the time that a diagnosis is made that countering the bacterial load is impossible even with the strongest available [[antibiotic]]s, for example [[gentamycin]] and [[vancomycin]]. [[Antibiotic]]s alone are not effective because they don't penetrate [[ischemic]] [[muscle]]s enough to be effective. There are two major reasons for this; current antibiotics only prevent replication of bacteria and the production of toxins continues in pre-existing bacteria. Also, the extent of injury caused by the infection may leave the muscle tissues so damaged that the body will never be able to replace the lost structures (including vasculature).

Currently, the use of [[penicillin G]] and [[clindamycin]] combination remains the most effective and preferred treatment.<ref name="Stevens-2005">{{Cite journal | last1 = Stevens | first1 = DL. | last2 = Bisno | first2 = AL. | last3 = Chambers | first3 = HF. | last4 = Everett | first4 = ED. | last5 = Dellinger | first5 = P. | last6 = Goldstein | first6 = EJ. | last7 = Gorbach | first7 = SL. | last8 = Hirschmann | first8 = JV. | last9 = Kaplan | first9 = EL. | title = Practice guidelines for the diagnosis and management of skin and soft-tissue infections. | journal = Clin Infect Dis | volume = 41 | issue = 10 | pages = 1373-406 | month = Nov | year = 2005 | doi = 10.1086/497143 | PMID = 16231249 }}</ref> Alternative drugs such as [[vancomycin]], [[linezolid]], [[quinupristin dalfopristin]], or [[daptomycin]] can be used in patients with severe [[Penicillin G benzathine adverse reactions|penicillin hypersensitivity]].

==Medical Therapy==

{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Gas Gangrene}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 600-900 mg IV q8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 2-4 million units q4–6h IV'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 2 gm IV q12h''''' OR ▸ '''''[[Erythromycin]] 1 gm q6h IV (not by bolus)'''''
|-
|}
|}

==References==
{{reflist|2}}

[[Category:Disease]]
[[Category:Surgery]]
[[Category:Pathology]]
[[Category:Infectious disease]]
[[Category:Needs content]]
[[Category:Bacterial diseases]]

{{WH}}
{{WS}}

Gas gangrene medical therapy

2014-05-19T18:57:46Z

Ayokunle Olubaniyi: /* Medical Therapy */

__NOTOC__
{{Gas gangrene}}
{{CMG}}; {{AE}}

==Overview==
Any significantly massive infection is a medical emergency. In cases of gangrene, the infection is so severe by the time that a diagnosis is made that countering the bacterial load is impossible even with the strongest available [[antibiotic]]s, for example [[gentamycin]] and [[vancomycin]]. [[Antibiotic]]s alone are not effective because they don't penetrate [[ischemic]] [[muscle]]s enough to be effective. There are two major reasons for this; current antibiotics only prevent replication of bacteria and the production of toxins continues in pre-existing bacteria. Also, the extent of injury caused by the infection may leave the muscle tissues so damaged that the body will never be able to replace the lost structures (including vasculature).

Currently, the use of [[penicillin G]] and [[clindamycin]] combination remains the most effective and preferred treatment.<ref name="Stevens-2005">{{Cite journal | last1 = Stevens | first1 = DL. | last2 = Bisno | first2 = AL. | last3 = Chambers | first3 = HF. | last4 = Everett | first4 = ED. | last5 = Dellinger | first5 = P. | last6 = Goldstein | first6 = EJ. | last7 = Gorbach | first7 = SL. | last8 = Hirschmann | first8 = JV. | last9 = Kaplan | first9 = EL. | title = Practice guidelines for the diagnosis and management of skin and soft-tissue infections. | journal = Clin Infect Dis | volume = 41 | issue = 10 | pages = 1373-406 | month = Nov | year = 2005 | doi = 10.1086/497143 | PMID = 16231249 }}</ref>

==Medical Therapy==

{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Gas Gangrene}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 600-900 mg IV q8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 2-4 million units q4–6h IV'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 2 gm IV q12h''''' OR ▸ '''''[[Erythromycin]] 1 gm q6h IV (not by bolus)'''''
|-
|}
|}

==References==
{{reflist|2}}

[[Category:Disease]]
[[Category:Surgery]]
[[Category:Pathology]]
[[Category:Infectious disease]]
[[Category:Needs content]]
[[Category:Bacterial diseases]]

{{WH}}
{{WS}}

Gas gangrene medical therapy

2014-05-19T18:53:15Z

Ayokunle Olubaniyi: /* Overview */

__NOTOC__
{{Gas gangrene}}
{{CMG}}; {{AE}}

==Overview==
Any significantly massive infection is a medical emergency. In cases of gangrene, the infection is so severe by the time that a diagnosis is made that countering the bacterial load is impossible even with the strongest available [[antibiotic]]s, for example [[gentamycin]] and [[vancomycin]]. [[Antibiotic]]s alone are not effective because they don't penetrate [[ischemic]] [[muscle]]s enough to be effective. There are two major reasons for this; current antibiotics only prevent replication of bacteria and the production of toxins continues in pre-existing bacteria. Also, the extent of injury caused by the infection may leave the muscle tissues so damaged that the body will never be able to replace the lost structures (including vasculature).

Currently, the use of [[penicillin G]] and [[clindamycin]] combination remains the most effective and preferred treatment.<ref name="Stevens-2005">{{Cite journal | last1 = Stevens | first1 = DL. | last2 = Bisno | first2 = AL. | last3 = Chambers | first3 = HF. | last4 = Everett | first4 = ED. | last5 = Dellinger | first5 = P. | last6 = Goldstein | first6 = EJ. | last7 = Gorbach | first7 = SL. | last8 = Hirschmann | first8 = JV. | last9 = Kaplan | first9 = EL. | title = Practice guidelines for the diagnosis and management of skin and soft-tissue infections. | journal = Clin Infect Dis | volume = 41 | issue = 10 | pages = 1373-406 | month = Nov | year = 2005 | doi = 10.1086/497143 | PMID = 16231249 }}</ref>

==Medical Therapy==

{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Gas Gangrene}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 900 mg IV q8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 24 million units/day divided q4–6h IV'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 2 gm IV q12h''''' OR ▸ '''''[[Erythromycin]] 1 gm q6h IV (not by bolus)'''''
|-
|}
|}

==References==
{{reflist|2}}

[[Category:Disease]]
[[Category:Surgery]]
[[Category:Pathology]]
[[Category:Infectious disease]]
[[Category:Needs content]]
[[Category:Bacterial diseases]]

{{WH}}
{{WS}}

Gas gangrene medical therapy

2014-05-19T18:51:36Z

Ayokunle Olubaniyi: /* Overview */

__NOTOC__
{{Gas gangrene}}
{{CMG}}; {{AE}}

==Overview==
Any significantly massive infection is a medical emergency. In cases of gangrene, the infection is so severe by the time that a diagnosis is made that countering the bacterial load is impossible even with the strongest available [[antibiotic]]s, for example [[gentamycin]] and [[vancomycin]]. [[Antibiotic]]s alone are not effective because they don't penetrate [[ischemic]] [[muscle]]s enough to be effective. Currently, the use of [[penicillin G]] and [[clindamycin]] combination remains the most effective and preferred treatment.<ref name="Stevens-2005">{{Cite journal | last1 = Stevens | first1 = DL. | last2 = Bisno | first2 = AL. | last3 = Chambers | first3 = HF. | last4 = Everett | first4 = ED. | last5 = Dellinger | first5 = P. | last6 = Goldstein | first6 = EJ. | last7 = Gorbach | first7 = SL. | last8 = Hirschmann | first8 = JV. | last9 = Kaplan | first9 = EL. | title = Practice guidelines for the diagnosis and management of skin and soft-tissue infections. | journal = Clin Infect Dis | volume = 41 | issue = 10 | pages = 1373-406 | month = Nov | year = 2005 | doi = 10.1086/497143 | PMID = 16231249 }}</ref>

There are two major reasons for this; current antibiotics only prevent replication of bacteria and the production of toxins continues in pre-existing bacteria. Also, the extent of injury caused by the infection may leave the muscle tissues so damaged that the body will never be able to replace the lost structures (including vasculature).

==Medical Therapy==

{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Gas Gangrene}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 900 mg IV q8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 24 million units/day divided q4–6h IV'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 2 gm IV q12h''''' OR ▸ '''''[[Erythromycin]] 1 gm q6h IV (not by bolus)'''''
|-
|}
|}

==References==
{{reflist|2}}

[[Category:Disease]]
[[Category:Surgery]]
[[Category:Pathology]]
[[Category:Infectious disease]]
[[Category:Needs content]]
[[Category:Bacterial diseases]]

{{WH}}
{{WS}}

Gas gangrene medical therapy

2014-05-19T18:50:53Z

Ayokunle Olubaniyi: /* Overview */

__NOTOC__
{{Gas gangrene}}
{{CMG}}; {{AE}}

==Overview==
Any significantly massive infection is a medical emergency. In cases of gangrene, the infection is so severe by the time that a diagnosis is made that countering the bacterial load is impossible even with the strongest available [[antibiotic]]s, for example [[gentamycin]] and [[vancomycin]]. [[Antibiotic]]s alone are not effective because they don't penetrate [[ischemic]] [[muscle]]s enough to be effective. Currently, the use of [[penicillin G]] and [[clindamycin]] combinatio remains the most effective and preferred treatment.<ref name="Stevens-2005">{{Cite journal | last1 = Stevens | first1 = DL. | last2 = Bisno | first2 = AL. | last3 = Chambers | first3 = HF. | last4 = Everett | first4 = ED. | last5 = Dellinger | first5 = P. | last6 = Goldstein | first6 = EJ. | last7 = Gorbach | first7 = SL. | last8 = Hirschmann | first8 = JV. | last9 = Kaplan | first9 = EL. | title = Practice guidelines for the diagnosis and management of skin and soft-tissue infections. | journal = Clin Infect Dis | volume = 41 | issue = 10 | pages = 1373-406 | month = Nov | year = 2005 | doi = 10.1086/497143 | PMID = 16231249 }}</ref>

There are two major reasons for this; current antibiotics only prevent replication of bacteria and the production of toxins continues in pre-existing bacteria. Also, the extent of injury caused by the infection may leave the muscle tissues so damaged that the body will never be able to replace the lost structures (including vasculature).

==Medical Therapy==

{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Gas Gangrene}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 900 mg IV q8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 24 million units/day divided q4–6h IV'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 2 gm IV q12h''''' OR ▸ '''''[[Erythromycin]] 1 gm q6h IV (not by bolus)'''''
|-
|}
|}

==References==
{{reflist|2}}

[[Category:Disease]]
[[Category:Surgery]]
[[Category:Pathology]]
[[Category:Infectious disease]]
[[Category:Needs content]]
[[Category:Bacterial diseases]]

{{WH}}
{{WS}}

Gas gangrene medical therapy

2014-05-19T15:40:53Z

Ayokunle Olubaniyi:

__NOTOC__
{{Gas gangrene}}
{{CMG}}; {{AE}}

==Overview==
Any significantly massive infection is a medical emergency. In cases of gangrene, the infection is so severe by the time that a diagnosis is made that countering the bacterial load is impossible even with the strongest available [[antibiotic]]s, for example [[gentamycin]] and [[vancomycin]]. [[Antibiotic]]s alone are not effective because they don't penetrate [[ischemic]] [[muscle]]s enough to be effective. However, penicillin is given as an [[adjuvant treatment]] to surgery.

There are two major reasons for this; current antibiotics only prevent replication of bacteria and the production of toxins continues in pre-existing bacteria. Also, the extent of injury caused by the infection may leave the muscle tissues so damaged that the body will never be able to replace the lost structures (including vasculature).

==Medical Therapy==

{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Gas Gangrene}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 900 mg IV q8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 24 million units/day divided q4–6h IV'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 2 gm IV q12h''''' OR ▸ '''''[[Erythromycin]] 1 gm q6h IV (not by bolus)'''''
|-
|}
|}

==References==
{{reflist|2}}

[[Category:Disease]]
[[Category:Surgery]]
[[Category:Pathology]]
[[Category:Infectious disease]]
[[Category:Needs content]]
[[Category:Bacterial diseases]]

{{WH}}
{{WS}}

Gas gangrene medical therapy

2014-05-19T15:19:15Z

Ayokunle Olubaniyi: /* Overview */

__NOTOC__
{{Gas gangrene}}
{{CMG}}; {{AE}}

==Overview==
Any significantly massive infection is a medical emergency. In cases of gangrene, the infection is so severe by the time that a diagnosis is made that countering the bacterial load is impossible even with the strongest available [[antibiotic]]s, for example [[gentamycin]] and [[vancomycin]]. [[Antibiotic]]s alone are not effective because they don't penetrate [[ischemic]] [[muscle]]s enough to be effective. However, penicillin is given as an [[adjuvant treatment]] to surgery.

There are two major reasons for this; current antibiotics only prevent replication of bacteria and the production of toxins continues in pre-existing bacteria. Also, the extent of injury caused by the infection may leave the muscle tissues so damaged that the body will never be able to replace the lost structures (including vasculature).

{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Gas Gangrene}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 900 mg IV q8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 24 million units/day divided q4–6h IV'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 2 gm IV q12h''''' OR ▸ '''''[[Erythromycin]] 1 gm q6h IV (not by bolus)'''''
|-
|}
|}

==References==
{{reflist|2}}

[[Category:Disease]]
[[Category:Surgery]]
[[Category:Pathology]]
[[Category:Infectious disease]]
[[Category:Needs content]]
[[Category:Bacterial diseases]]

{{WH}}
{{WS}}

Sandbox/22

2014-05-19T14:56:53Z

Ayokunle Olubaniyi: /* Gas gangrene */

==Gas gangrene==
{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Infection}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Drug A]] 50 mg/kg IV q8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Drug B]] 50 mg/kg IV q8—12h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Drug C]] 50 mg/kg IV q8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Drug D]] 2.5 mg/kg IV q8h''''' OR ▸ '''''[[Drug E]] 2.5 mg/kg IV q8h'''''
|-
|}
|}

==CHF==
{{familytree/start}}
{{familytree | | | |!| | | |!| | |}}
{{familytree | | | E01 |~| E02 | |E01=[[Chronic heart failure resident survival guide#Diuretic Therapy|Diuretic therapy]]|E02= [[ACE inhibitors]] '''AND''' [[Beta blockers]]}}
{{familytree | | | | | | | |!| |}}
{{familytree | | | | | | | F01 | |F01=Intolerant to ACE-I}}
{{familytree | | | | | |,|-|^|-|.| |}}
{{familytree | | | | | G01 | | G02 | |G01=[[Cough]]|G02=[[Renal insufficiency]] or [[angioedema]]}}
{{familytree | | | | | |!| | | |!| |}}
{{familytree | | | | | H01 | | H02 | |H01=[[Angiotensin II receptor antagonist|ARBs]]|H02=[[Hydralazine]]/[[isosorbide dinitrate]]<ref name="pmid3520315">{{cite journal| author=Cohn JN, Archibald DG, Ziesche S, Franciosa JA, Harston WE, Tristani FE et al.| title=Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative Study. | journal=N Engl J Med | year= 1986 | volume= 314 | issue= 24 | pages= 1547-52 | pmid=3520315 | doi=10.1056/NEJM198606123142404 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3520315 }} </ref>}}
{{familytree | | | | | |`|-|v|-|'| |}}
{{familytree | | | | | | | I01 | | | I01=Persistent symptoms?}}
{{familytree | | | | | |,|-|^|-|.| |}}
{{familytree | | | | | J01 | | J02 | J01='''Yes'''|J02='''No'''}}
{{familytree | | | | | |!| | | |!| | }}
{{familytree | | | | | K01 | | |!| | K01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Add:''' 
❑ [[Aldosterone]] or [[eplerenone]] if: 
:❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
:❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
:❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
:❑ NYHA class II–IV HF with LVEF ≤ 35% '''OR''' 
❑ [[Hydralazine]]/[[isosorbide dinitrate]] 
:❑ African Americans with NYHA class III–IV HFrEF on GDMT '''OR''' 
❑ [[ARBs]]<ref name="pmid13678868">{{cite journal| author=Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, Michelson EL et al.| title=Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme. | journal=Lancet | year= 2003 | volume= 362 | issue= 9386 | pages= 759-66 | pmid=13678868 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13678868 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15122853 Review in: ACP J Club. 2004 Mar-Apr;140(2):32-3] </ref>

</div>}}
{{familytree | | | | | |!| | | |!| | |}}
{{familytree | | | | | L01 | | |!| | |L01=Persistent symptoms?}}
{{familytree | | | | | |!| | | |!| |}}
{{familytree | | | | | M01 | | |!| |M01=Add [[digoxin]] }}
{{familytree | | | | | |!| | | |!| | |}}
{{familytree | | | | | N01 | | |!| | |N01=Persistent symptoms?}}
{{familytree | | | |,|-|^|-|.| |!| | }}
{{familytree | | | O01 | | O02 |!| | |O01='''Yes'''|O02='''No'''}}
{{familytree | | | |!| | | |`|-|^|-|.| | |}}
{{familytree | | | P01 | | | | | | P02 | | | | P01=<div style="float: left; text-align: left; width: 15em; padding:1em;">
❑ LVEF ≤ 35% 
❑ Sinus rhythm or [[Left bundle branch block|LBBB]] 
❑ [[Chronic heart failure resident survival guide#New York Heart Association (NYHA)|NYHA]] III - IV </div>|P02=LVEF ≤ 35%?}}
{{familytree | |,|-|^|-|.| | | |,|-|^|-|.| | |}}
{{familytree | Q01 | | Q02 | | Q03 | | Q04 | | |Q01='''Yes'''|Q02='''No'''|Q03='''Yes'''|Q04='''No'''}}
{{familytree | |!| | | |!| | | |!| | | |!| |}}
{{familytree | R01 | | |!| | | R02 | | R03 | |R01=[[Cardiac resynchronization therapy]] (CRT) ± [[Implantable cardioverter defibrillator]] (ICD)|R02=<div style="float: left; text-align: left; width: 15em; padding:1em;">[[Implantable cardioverter defibrillator]] 
❑ As primary prevention of [[sudden cardiac death]] in:
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT </div>|R03=Continue GDMT}}
{{familytree | |`|-|v|-|'| | |}}
{{familytree | | | S01 | | |S01=Persistent symptoms (Advanced heart failure)}}
{{familytree | | | |!| | |}}
{{familytree | | | T01 | |T01=IV inotropes or vasodilators }}
{{familytree | | | |!| | |}}
{{familytree | | | U01 | | U01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''[[Mechanical circulatory support]] (MCS)<ref name="pmid21300961">{{cite journal| author=Naidu SS| title=Novel percutaneous cardiac assist devices: the science of and indications for hemodynamic support. | journal=Circulation | year= 2011 | volume= 123 | issue= 5 | pages= 533-43 | pmid=21300961 | doi=10.1161/CIRCULATIONAHA.110.945055 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21300961 }} </ref>:''' 
* [[Intra-aortic balloon pump]] 
* [[Ventricular assist device|LVAD]] - as bridge to recovery,<ref name="pmid17079761">{{cite journal| author=Birks EJ, Tansley PD, Hardy J, George RS, Bowles CT, Burke M et al.| title=Left ventricular assist device and drug therapy for the reversal of heart failure. | journal=N Engl J Med | year= 2006 | volume= 355 | issue= 18 | pages= 1873-84 | pmid=17079761 | doi=10.1056/NEJMoa053063 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17079761 }} </ref> transplant, or as definitive therapy<ref name="pmid19920051">{{cite journal| author=Slaughter MS, Rogers JG, Milano CA, Russell SD, Conte JV, Feldman D et al.| title=Advanced heart failure treated with continuous-flow left ventricular assist device. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 23 | pages= 2241-51 | pmid=19920051 | doi=10.1056/NEJMoa0909938 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19920051 }} </ref> 
❑ General indications:
:❑ LVEF ≤ 25% 
:❑ NYHA III or IV on chronic GDMT 
:❑ Predicted 1-2 year mortality</div>|R03=Continue GDMT</div>}}
{{familytree | | | |!| |}}
{{familytree | | | V01 | V01=[[Heart transplantation|Cardiac transplantation]]}}
{{familytree/end}}

==Hypertension==
{{familytree/start}}
{{familytree | |,|-|-|-|v|-|-|^|-|-|v|-|-|-|.| | |}}
{{familytree | J01 | | J02 | | | | J03 |~| J04 | | |J01=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Dry''' 
----
❑ Consider outpatient treatment ❑ Dietary sodium restriction (2-3 g daily) ❑ [[Smoking cessation]] ❑ [[Alcohol]] abstinence (≤2 standard drinks per day for men; ≤1 for women) ❑ Encourage exercise/physical activity 
'''Although [[ACE inhibitors]] and [[beta blockers]] should not be administered to patients with [[acute decompensated heart failure]], if the patient is compensated in the outpatient setting then administer: ❑ [[ACE inhibitors]] or ([[ARBs]]) if LVEF is ≤ 40% ❑ [[Beta blockers]]'''<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> </div>|

J02=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Wet''' 
----
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] 
❑ Treat co-morbidities [[HTN]], [[DM]], [[CAD]], [[AF]]</div>|

J03=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Wet''' 
----
❑ CCU admission 
❑ Invasive hemodynamic monitoring (arterial line, consider pulmonary catheter if volume status unclear) 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) ❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] while monitoring [[blood pressure]] ❑ IV vasodilators</div>|J04=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Dry''' 
----
❑ CCU admission 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) 
❑ '''Persistent organ hypoperfusion''' (e.g., low urine output or persistent low SBP<85) 
:❑ [[Norepinephrine]] 0.2–1.0 mcg/kg/min, titrate to maintain a blood pressure of </div>}}
{{familytree | | | | | |!| | | | | |!| | | |!| | | | |}}
{{familytree | | | | | |`|-|-|v|-|-|^|-|-|-|'| | |}}
{{familytree | | | | | | | | X01 | | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | K01 | | | |K01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | | | | | |}}
{{familytree | | | | | | | | L01 | | | |L01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

Gas gangrene medical therapy

2014-05-19T14:54:08Z

Ayokunle Olubaniyi:

Sandbox/22

2014-05-19T14:51:53Z

Ayokunle Olubaniyi:

==Gas gangrene==

==CHF==
{{familytree/start}}
{{familytree | | | |!| | | |!| | |}}
{{familytree | | | E01 |~| E02 | |E01=[[Chronic heart failure resident survival guide#Diuretic Therapy|Diuretic therapy]]|E02= [[ACE inhibitors]] '''AND''' [[Beta blockers]]}}
{{familytree | | | | | | | |!| |}}
{{familytree | | | | | | | F01 | |F01=Intolerant to ACE-I}}
{{familytree | | | | | |,|-|^|-|.| |}}
{{familytree | | | | | G01 | | G02 | |G01=[[Cough]]|G02=[[Renal insufficiency]] or [[angioedema]]}}
{{familytree | | | | | |!| | | |!| |}}
{{familytree | | | | | H01 | | H02 | |H01=[[Angiotensin II receptor antagonist|ARBs]]|H02=[[Hydralazine]]/[[isosorbide dinitrate]]<ref name="pmid3520315">{{cite journal| author=Cohn JN, Archibald DG, Ziesche S, Franciosa JA, Harston WE, Tristani FE et al.| title=Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative Study. | journal=N Engl J Med | year= 1986 | volume= 314 | issue= 24 | pages= 1547-52 | pmid=3520315 | doi=10.1056/NEJM198606123142404 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3520315 }} </ref>}}
{{familytree | | | | | |`|-|v|-|'| |}}
{{familytree | | | | | | | I01 | | | I01=Persistent symptoms?}}
{{familytree | | | | | |,|-|^|-|.| |}}
{{familytree | | | | | J01 | | J02 | J01='''Yes'''|J02='''No'''}}
{{familytree | | | | | |!| | | |!| | }}
{{familytree | | | | | K01 | | |!| | K01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Add:''' 
❑ [[Aldosterone]] or [[eplerenone]] if: 
:❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
:❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
:❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
:❑ NYHA class II–IV HF with LVEF ≤ 35% '''OR''' 
❑ [[Hydralazine]]/[[isosorbide dinitrate]] 
:❑ African Americans with NYHA class III–IV HFrEF on GDMT '''OR''' 
❑ [[ARBs]]<ref name="pmid13678868">{{cite journal| author=Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, Michelson EL et al.| title=Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme. | journal=Lancet | year= 2003 | volume= 362 | issue= 9386 | pages= 759-66 | pmid=13678868 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13678868 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15122853 Review in: ACP J Club. 2004 Mar-Apr;140(2):32-3] </ref>

</div>}}
{{familytree | | | | | |!| | | |!| | |}}
{{familytree | | | | | L01 | | |!| | |L01=Persistent symptoms?}}
{{familytree | | | | | |!| | | |!| |}}
{{familytree | | | | | M01 | | |!| |M01=Add [[digoxin]] }}
{{familytree | | | | | |!| | | |!| | |}}
{{familytree | | | | | N01 | | |!| | |N01=Persistent symptoms?}}
{{familytree | | | |,|-|^|-|.| |!| | }}
{{familytree | | | O01 | | O02 |!| | |O01='''Yes'''|O02='''No'''}}
{{familytree | | | |!| | | |`|-|^|-|.| | |}}
{{familytree | | | P01 | | | | | | P02 | | | | P01=<div style="float: left; text-align: left; width: 15em; padding:1em;">
❑ LVEF ≤ 35% 
❑ Sinus rhythm or [[Left bundle branch block|LBBB]] 
❑ [[Chronic heart failure resident survival guide#New York Heart Association (NYHA)|NYHA]] III - IV </div>|P02=LVEF ≤ 35%?}}
{{familytree | |,|-|^|-|.| | | |,|-|^|-|.| | |}}
{{familytree | Q01 | | Q02 | | Q03 | | Q04 | | |Q01='''Yes'''|Q02='''No'''|Q03='''Yes'''|Q04='''No'''}}
{{familytree | |!| | | |!| | | |!| | | |!| |}}
{{familytree | R01 | | |!| | | R02 | | R03 | |R01=[[Cardiac resynchronization therapy]] (CRT) ± [[Implantable cardioverter defibrillator]] (ICD)|R02=<div style="float: left; text-align: left; width: 15em; padding:1em;">[[Implantable cardioverter defibrillator]] 
❑ As primary prevention of [[sudden cardiac death]] in:
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT </div>|R03=Continue GDMT}}
{{familytree | |`|-|v|-|'| | |}}
{{familytree | | | S01 | | |S01=Persistent symptoms (Advanced heart failure)}}
{{familytree | | | |!| | |}}
{{familytree | | | T01 | |T01=IV inotropes or vasodilators }}
{{familytree | | | |!| | |}}
{{familytree | | | U01 | | U01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''[[Mechanical circulatory support]] (MCS)<ref name="pmid21300961">{{cite journal| author=Naidu SS| title=Novel percutaneous cardiac assist devices: the science of and indications for hemodynamic support. | journal=Circulation | year= 2011 | volume= 123 | issue= 5 | pages= 533-43 | pmid=21300961 | doi=10.1161/CIRCULATIONAHA.110.945055 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21300961 }} </ref>:''' 
* [[Intra-aortic balloon pump]] 
* [[Ventricular assist device|LVAD]] - as bridge to recovery,<ref name="pmid17079761">{{cite journal| author=Birks EJ, Tansley PD, Hardy J, George RS, Bowles CT, Burke M et al.| title=Left ventricular assist device and drug therapy for the reversal of heart failure. | journal=N Engl J Med | year= 2006 | volume= 355 | issue= 18 | pages= 1873-84 | pmid=17079761 | doi=10.1056/NEJMoa053063 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17079761 }} </ref> transplant, or as definitive therapy<ref name="pmid19920051">{{cite journal| author=Slaughter MS, Rogers JG, Milano CA, Russell SD, Conte JV, Feldman D et al.| title=Advanced heart failure treated with continuous-flow left ventricular assist device. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 23 | pages= 2241-51 | pmid=19920051 | doi=10.1056/NEJMoa0909938 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19920051 }} </ref> 
❑ General indications:
:❑ LVEF ≤ 25% 
:❑ NYHA III or IV on chronic GDMT 
:❑ Predicted 1-2 year mortality</div>|R03=Continue GDMT</div>}}
{{familytree | | | |!| |}}
{{familytree | | | V01 | V01=[[Heart transplantation|Cardiac transplantation]]}}
{{familytree/end}}

==Hypertension==
{{familytree/start}}
{{familytree | |,|-|-|-|v|-|-|^|-|-|v|-|-|-|.| | |}}
{{familytree | J01 | | J02 | | | | J03 |~| J04 | | |J01=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Dry''' 
----
❑ Consider outpatient treatment ❑ Dietary sodium restriction (2-3 g daily) ❑ [[Smoking cessation]] ❑ [[Alcohol]] abstinence (≤2 standard drinks per day for men; ≤1 for women) ❑ Encourage exercise/physical activity 
'''Although [[ACE inhibitors]] and [[beta blockers]] should not be administered to patients with [[acute decompensated heart failure]], if the patient is compensated in the outpatient setting then administer: ❑ [[ACE inhibitors]] or ([[ARBs]]) if LVEF is ≤ 40% ❑ [[Beta blockers]]'''<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> </div>|

J02=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Wet''' 
----
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] 
❑ Treat co-morbidities [[HTN]], [[DM]], [[CAD]], [[AF]]</div>|

J03=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Wet''' 
----
❑ CCU admission 
❑ Invasive hemodynamic monitoring (arterial line, consider pulmonary catheter if volume status unclear) 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) ❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] while monitoring [[blood pressure]] ❑ IV vasodilators</div>|J04=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Dry''' 
----
❑ CCU admission 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) 
❑ '''Persistent organ hypoperfusion''' (e.g., low urine output or persistent low SBP<85) 
:❑ [[Norepinephrine]] 0.2–1.0 mcg/kg/min, titrate to maintain a blood pressure of </div>}}
{{familytree | | | | | |!| | | | | |!| | | |!| | | | |}}
{{familytree | | | | | |`|-|-|v|-|-|^|-|-|-|'| | |}}
{{familytree | | | | | | | | X01 | | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | K01 | | | |K01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | | | | | |}}
{{familytree | | | | | | | | L01 | | | |L01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

Chronic heart failure resident survival guide

2014-05-09T16:46:16Z

Ayokunle Olubaniyi:

<div style="width: 80%;">
__NOTOC__
{{CMG}}; {{AE}} {{AO}}
{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Chronic Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Treatment|Treatment]]
:[[Chronic heart failure resident survival guide#Diuretic Therapy Details|Diuretic Therapy]]
:[[Chronic heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
There are several goals in the chronic management of systolic [[heart failure]]. One goal of therapy is to improve the patient's symptoms, exercise tolerance and quality of life. [[Diuretics]], along with regular assessment of the patient's weight, minimizes fluid accumulation and the accompanying symptoms of [[dyspnea]] and [[orthopnea]]. Another goal is to reduce hospitalization and mortality. To achieve the second goal, patients with chronic [[heart failure]] should be administered an [[ACE inhibitor]] (or [[ARB]] if they are [[ACE]] intolerant) and a [[beta blocker]]. If the patient remains symptomatic, additional therapy may include an [[aldosterone antagonist]].

====Goals of Therapy====
{|class="wikitable"
! Goals!!Therapeutic intervention
|-
| To alleviate symptoms and signs||[[Diuretics]], [[morphine]] (no mortality benefit)
|-
| To reduce mortality||[[ACE inhibitors]]<ref name="pmid2883575">{{cite journal| author=| title=Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group. | journal=N Engl J Med | year= 1987 | volume= 316 | issue= 23 | pages= 1429-35 | pmid=2883575 | doi=10.1056/NEJM198706043162301 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2883575 }} </ref><ref name="pmid7654275">{{cite journal| author=Garg R, Yusuf S| title=Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. | journal=JAMA | year= 1995 | volume= 273 | issue= 18 | pages= 1450-6 | pmid=7654275 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7654275 }} </ref>, [[ARBs]], [[beta blockers]]<ref name="pmid11851582">{{cite journal| author=Foody JM, Farrell MH, Krumholz HM| title=beta-Blocker therapy in heart failure: scientific review. | journal=JAMA | year= 2002 | volume= 287 | issue= 7 | pages= 883-9 | pmid=11851582 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11851582 }} </ref>, [[aldosterone antagonists]]<ref name="pmid21073363">{{cite journal| author=Zannad F, McMurray JJ, Krum H, van Veldhuisen DJ, Swedberg K, Shi H et al.| title=Eplerenone in patients with systolic heart failure and mild symptoms. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 1 | pages= 11-21 | pmid=21073363 | doi=10.1056/NEJMoa1009492 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21073363 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21814643 Review in: J Fam Pract. 2011 Aug;60(8):482-4] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21558564 Review in: Evid Based Med. 2011 Aug;16(4):121-2] </ref>, [[hydralazine]] plus [[isosorbide dinitrate]]<ref name="pmid2057035">{{cite journal| author=Cohn JN, Johnson G, Ziesche S, Cobb F, Francis G, Tristani F et al.| title=A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. | journal=N Engl J Med | year= 1991 | volume= 325 | issue= 5 | pages= 303-10 | pmid=2057035 | doi=10.1056/NEJM199108013250502 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2057035 }} </ref>, [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref><ref name="pmid16087142">{{cite journal| author=Macchia A, Levantesi G, Franzosi MG, Geraci E, Maggioni AP, Marfisi R et al.| title=Left ventricular systolic dysfunction, total mortality, and sudden death in patients with myocardial infarction treated with n-3 polyunsaturated fatty acids. | journal=Eur J Heart Fail | year= 2005 | volume= 7 | issue= 5 | pages= 904-9 | pmid=16087142 | doi=10.1016/j.ejheart.2005.04.008 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16087142 }} </ref>, [[Cardiac resynchronization therapy|CRT]]<ref name="pmid15753115">{{cite journal| author=Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L et al.| title=The effect of cardiac resynchronization on morbidity and mortality in heart failure. | journal=N Engl J Med | year= 2005 | volume= 352 | issue= 15 | pages= 1539-49 | pmid=15753115 | doi=10.1056/NEJMoa050496 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15753115 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16134903 Review in: ACP J Club. 2005 Sep-Oct;143(2):29] </ref>, [[Implantable cardioverter defibrillator|ICD]]<ref name="pmid15659722">{{cite journal| author=Bardy GH, Lee KL, Mark DB, Poole JE, Packer DL, Boineau R et al.| title=Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. | journal=N Engl J Med | year= 2005 | volume= 352 | issue= 3 | pages= 225-37 | pmid=15659722 | doi=10.1056/NEJMoa043399 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15659722 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15989294 Review in: ACP J Club. 2005 Jul-Aug;143(1):6] </ref>
|-
| To reduce hospitalization||[[Digoxin]]<ref name="pmid9036306">{{cite journal| author=Digitalis Investigation Group| title=The effect of digoxin on mortality and morbidity in patients with heart failure. | journal=N Engl J Med | year= 1997 | volume= 336 | issue= 8 | pages= 525-33 | pmid=9036306 | doi=10.1056/NEJM199702203360801 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9036306 }} </ref>, [[ARBs]] (in [[Diastolic dysfunction|HFpEF]])<ref name="pmid13678871">{{cite journal| author=Yusuf S, Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ et al.| title=Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial. | journal=Lancet | year= 2003 | volume= 362 | issue= 9386 | pages= 777-81 | pmid=13678871 | doi=10.1016/S0140-6736(03)14285-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13678871 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15122853 Review in: ACP J Club. 2004 Mar-Apr;140(2):32-3] </ref>
|}

==Classification==
====Based on the Stage of Heart Failure====
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

====Based on the Severity of Congestive Heart Failure====
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Chronic heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.

===Common Causes===
* Cardiotoxic drugs (e.g. [[NSAIDs]], [[thiazolidinedione]], and certain [[chemotherapy]] drugs)
* [[Sepsis|Concurrent infections]] e.g., [[pneumonia]], viral illnesses
* Electrolyte imbalances
* Endocrine abnormalities - [[diabetes mellitus]], thyroid disorders ([[hyperthyroidism]], [[hypothyroidism]])
* Excessive [[alcohol]] or illicit drug use (e.g. [[cocaine]])
* Medication noncompliance
* [[Myocardial ischemia]] or [[infarction]]
* Noncompliance with dietary restrictions (e.g., sodium and fluid restriction)
* Progressive valvular disease (e.g. [[mitral regurgitation]])
* [[Pulmonary embolus]]
* [[Cardiac arrhythmias|Uncontrolled arrhythmias]]
* [[Hypertension|Uncontrolled hypertension]]

==Complete Diagnostic Approach==
The algorithm below describes the diagnostic approach to a patient with chronic heart failure.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' Acute respiratory distress syndrome;
'''BNP:''' B-type natriuretic peptide;
'''BUN:''' Blood urea nitrogen;
'''CAD:''' Coronary artery disease;
'''CBC:''' Complete blood count;
'''CCB:''' Calcium channel blocker;
'''CT:''' Computed tomography;
'''CXR:''' Chest x-ray;
'''DM:''' Diabetes mellitus;
'''EKG:''' Electrocardiogram;
'''HTN:''' Hypertension;
'''LVEF:''' Left ventricular ejection fraction;
'''LVH:''' Left ventricular hypertrophy;
'''MI:''' Myocardial infarction;
'''MRI:''' Magnetic resonance imaging;
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' Oral contraceptive pills;
'''PAWP:''' Pulmonary artery wedge pressure
'''TSH:''' Thyroid stimulating hormone
 

{{familytree/start}}
{{familytree | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
'''Symptoms of fluid accumulation:''' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
'''Symptoms of reduced cardiac output:''' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (may be suggestive of [[mesenteric ischemia]]) 
'''Symptoms suggestive of precipitating events:''' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitation]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
'''Nonspecific symptoms:''' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
'''Obtain a detailed history:''' 
❑ '''Past medical history:''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history:''' 
:❑ Noncompliance with medications 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s 
::❑ [[Thiazolidinedione]] 
❑ '''Family history:''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 
'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying infection) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] 
'''Assess weight:''' 
:❑ Subtract 'dry weight' from value to assess [[edema]] 
'''Skin:''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] 
'''Respiratory examination:''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 
'''Cardiovascular examination:''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (when right ventricular pressure is increased) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 
'''Abdominal examination:''' 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 
'''Extremity examination:''' 
❑ [[Pedal edema]] 
'''Neurological examination:''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | Q01 | |Q01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref> 
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] 
:❑ [[BUN]], [[creatinine]] 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 35 pg/mL 
:❑ NT-pro BNP ≤ 125 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ Cephalization
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior MI) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] (LBBB) 
:❑ [[Left atrial enlargement]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes 
❑ 2-D [[echocardiography]] with doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess LVEF and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] - in [[respiratory distress]] or [[shock]] 
'''Additional tests to rule out other etiologies:''' 
----
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
----
{{familytree | | | | | |!| | |}}
{{familytree | | | | | Y01 | |Y01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[COPD]]</td><td>❑ [[Dyspnea]], [[cough]], [[sputum]], history of smoking ❑ [[Spirometry]] reveals obstructive pattern</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ CXR - [[Pneumonia chest x ray|consolidation]]</td></tr>
<tr><td> [[Liver cirrhosis]]</td><td>❑ [[Jaundice]], [[fatigue]], [[peripheral edema]], [[coagulopathy]] ❑ Abnormal [[liver function tests]] ❑ [[Liver biopsy]] confirms the underlying cause</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors - trauma, immobilization, smoking, OCPs ❑ CT pulmonary angiography - clot in pulmonary artery</td></tr>
<tr><td>[[Peripartum cardiomyopathy]] </td><td>❑ [[Dyspnea]], [[orthopnea]], [[PND]] ❑ [[Pregnancy]] ❑ Absence of heart disease prior to onset of heart failure ❑ [[Echocardiography]] confirms [[left ventricular enlargement]] and [[systolic dysfunction]]</td></tr>
<tr><td>[[Nephrotic syndrome]] </td><td>❑ [[Dyspnea]], [[fatigue]], [[peripheral edema]] ❑ [[Urinalysis]] reveals [[proteinuria]] > 3.5g/24 hours</td></tr>
</table></div>}}
{{familytree/end}}

==Treatment==
{{familytree/start}}
{{familytree | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | C01 | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status''' 
❑ [[Congestion|Congestion at rest]] e.g., [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]] 
❑ Low perfusion at rest e.g., [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | Z01 | | | |Z01='''Classify the patient based on the left ventricular ejection fraction'''}}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01='''Systolic heart failure LVEF ≤ 40%'''|D02='''Diastolic heart failure LVEF ≥ 50%'''}}
{{familytree | | | |!| | | |}}
{{familytree | | | E01 | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''First step: Diuresis''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>
}}
{{familytree | | | |!| | | |}}
{{familytree | | | F01 | | |F01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Second step: ACE Inhibition and Angiotensin Receptor Blockade''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>
}}
{{familytree | | | |!| | |}}
{{familytree | | | G01 | |G01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Third step: Beta blockers''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree | | | |!| | |}}
{{familytree | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Fourth step: Aldosterone Antagonism''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree | | | |!| | |}}
{{familytree | | | I01 | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Fifth step: The Combination of Hydralazine and a Nitrate''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree | | | |!| | |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Sixth step: Digoxin''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

==== Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Ensure guideline-directed medical therapy (GDMT) - This is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible if no recent one available or if the patient's clinical status is deteriorating.
* Digitalis decreases hospitalization but not mortality. It can be beneficial in symptomatic patients with low EF.<ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an
episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* Make sure your patient is on [[DVT]] prophylaxis unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

Advanced heart failure refers to severe symptoms of heart failure with [[dyspnea]] and/or [[fatigue]] at rest or with minimal exertion (NYHA class III or IV). These parameters assist in identifying patients with advanced heart failure:
<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref>

* Repeated (≥2) hospitalizations or ED visits for HF in the past year
* Progressive deterioration in renal function (eg, rise in BUN and [[creatinine]])
* Weight loss without other cause (eg, cardiac cachexia)
* Intolerance to ACE inhibitors due to [[hypotension]] and/or worsening renal function
* Intolerance to beta blockers due to worsening HF or hypotension
* Frequent systolic blood pressure <90 mm Hg
* Persistent [[dyspnea]] with dressing or bathing requiring rest
* Inability to walk 1 block on the level ground due to dyspnea or fatigue
* Recent need to escalate diuretics to maintain volume status, often reaching daily [[furosemide]] equivalent dose over 160 mg/d and/or use of supplemental [[metolazone]] therapy
* Progressive decline in serum sodium, usually to < 133 mEq/L
* Frequent ICD shocks

==Don'ts==
* Avoid the use of [[NSAIDs]], sympathomimetics, [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine calcium channel blockers ([[diltiazem]], [[verapamil]].<ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't Use parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal functions worsening and hyperkalemia.
* Avoid using [[statins]] solely for [[heart failure]]. It adds no benefit.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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</div>

Chronic heart failure resident survival guide

2014-05-09T16:44:52Z

Ayokunle Olubaniyi:

Chronic heart failure resident survival guide

2014-05-09T16:43:25Z

Ayokunle Olubaniyi: /* Medications */

<div style="width: 80%;">
__NOTOC__
{{CMG}}; {{AE}} {{AO}}
{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Chronic Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Diagnosis|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Treatment|Treatment]]
:[[Chronic heart failure resident survival guide#Diuretic Therapy|Diuretic Therapy]]
:[[Chronic heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
There are several goals in the chronic management of systolic [[heart failure]]. One goal of therapy is to improve the patient's symptoms, exercise tolerance and quality of life. [[Diuretics]], along with regular assessment of the patient's weight, minimizes fluid accumulation and the accompanying symptoms of [[dyspnea]] and [[orthopnea]]. Another goal is to reduce hospitalization and mortality. To achieve the second goal, patients with chronic [[heart failure]] should be administered an [[ACE inhibitor]] (or [[ARB]] if they are [[ACE]] intolerant) and a [[beta blocker]]. If the patient remains symptomatic, additional therapy may include an [[aldosterone antagonist]].

====Goals of Therapy====
{|class="wikitable"
! Goals!!Therapeutic intervention
|-
| To alleviate symptoms and signs||[[Diuretics]], [[morphine]] (no mortality benefit)
|-
| To reduce mortality||[[ACE inhibitors]]<ref name="pmid2883575">{{cite journal| author=| title=Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group. | journal=N Engl J Med | year= 1987 | volume= 316 | issue= 23 | pages= 1429-35 | pmid=2883575 | doi=10.1056/NEJM198706043162301 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2883575 }} </ref><ref name="pmid7654275">{{cite journal| author=Garg R, Yusuf S| title=Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. | journal=JAMA | year= 1995 | volume= 273 | issue= 18 | pages= 1450-6 | pmid=7654275 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7654275 }} </ref>, [[ARBs]], [[beta blockers]]<ref name="pmid11851582">{{cite journal| author=Foody JM, Farrell MH, Krumholz HM| title=beta-Blocker therapy in heart failure: scientific review. | journal=JAMA | year= 2002 | volume= 287 | issue= 7 | pages= 883-9 | pmid=11851582 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11851582 }} </ref>, [[aldosterone antagonists]]<ref name="pmid21073363">{{cite journal| author=Zannad F, McMurray JJ, Krum H, van Veldhuisen DJ, Swedberg K, Shi H et al.| title=Eplerenone in patients with systolic heart failure and mild symptoms. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 1 | pages= 11-21 | pmid=21073363 | doi=10.1056/NEJMoa1009492 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21073363 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21814643 Review in: J Fam Pract. 2011 Aug;60(8):482-4] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21558564 Review in: Evid Based Med. 2011 Aug;16(4):121-2] </ref>, [[hydralazine]] plus [[isosorbide dinitrate]]<ref name="pmid2057035">{{cite journal| author=Cohn JN, Johnson G, Ziesche S, Cobb F, Francis G, Tristani F et al.| title=A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. | journal=N Engl J Med | year= 1991 | volume= 325 | issue= 5 | pages= 303-10 | pmid=2057035 | doi=10.1056/NEJM199108013250502 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2057035 }} </ref>, [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref><ref name="pmid16087142">{{cite journal| author=Macchia A, Levantesi G, Franzosi MG, Geraci E, Maggioni AP, Marfisi R et al.| title=Left ventricular systolic dysfunction, total mortality, and sudden death in patients with myocardial infarction treated with n-3 polyunsaturated fatty acids. | journal=Eur J Heart Fail | year= 2005 | volume= 7 | issue= 5 | pages= 904-9 | pmid=16087142 | doi=10.1016/j.ejheart.2005.04.008 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16087142 }} </ref>, [[Cardiac resynchronization therapy|CRT]]<ref name="pmid15753115">{{cite journal| author=Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L et al.| title=The effect of cardiac resynchronization on morbidity and mortality in heart failure. | journal=N Engl J Med | year= 2005 | volume= 352 | issue= 15 | pages= 1539-49 | pmid=15753115 | doi=10.1056/NEJMoa050496 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15753115 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16134903 Review in: ACP J Club. 2005 Sep-Oct;143(2):29] </ref>, [[Implantable cardioverter defibrillator|ICD]]<ref name="pmid15659722">{{cite journal| author=Bardy GH, Lee KL, Mark DB, Poole JE, Packer DL, Boineau R et al.| title=Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. | journal=N Engl J Med | year= 2005 | volume= 352 | issue= 3 | pages= 225-37 | pmid=15659722 | doi=10.1056/NEJMoa043399 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15659722 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15989294 Review in: ACP J Club. 2005 Jul-Aug;143(1):6] </ref>
|-
| To reduce hospitalization||[[Digoxin]]<ref name="pmid9036306">{{cite journal| author=Digitalis Investigation Group| title=The effect of digoxin on mortality and morbidity in patients with heart failure. | journal=N Engl J Med | year= 1997 | volume= 336 | issue= 8 | pages= 525-33 | pmid=9036306 | doi=10.1056/NEJM199702203360801 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9036306 }} </ref>, [[ARBs]] (in [[Diastolic dysfunction|HFpEF]])<ref name="pmid13678871">{{cite journal| author=Yusuf S, Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ et al.| title=Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial. | journal=Lancet | year= 2003 | volume= 362 | issue= 9386 | pages= 777-81 | pmid=13678871 | doi=10.1016/S0140-6736(03)14285-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13678871 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15122853 Review in: ACP J Club. 2004 Mar-Apr;140(2):32-3] </ref>
|}

==Classification==
====Based on the Stage of Heart Failure====
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

====Based on the Severity of Congestive Heart Failure====
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Chronic heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.

===Common Causes===
* Cardiotoxic drugs (e.g. [[NSAIDs]], [[thiazolidinedione]], and certain [[chemotherapy]] drugs)
* [[Sepsis|Concurrent infections]] e.g., [[pneumonia]], viral illnesses
* Electrolyte imbalances
* Endocrine abnormalities - [[diabetes mellitus]], thyroid disorders ([[hyperthyroidism]], [[hypothyroidism]])
* Excessive [[alcohol]] or illicit drug use (e.g. [[cocaine]])
* Medication noncompliance
* [[Myocardial ischemia]] or [[infarction]]
* Noncompliance with dietary restrictions (e.g., sodium and fluid restriction)
* Progressive valvular disease (e.g. [[mitral regurgitation]])
* [[Pulmonary embolus]]
* [[Cardiac arrhythmias|Uncontrolled arrhythmias]]
* [[Hypertension|Uncontrolled hypertension]]

==Complete Diagnostic Approach==
The algorithm below describes the diagnostic approach to a patient with chronic heart failure.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' Acute respiratory distress syndrome;
'''BNP:''' B-type natriuretic peptide;
'''BUN:''' Blood urea nitrogen;
'''CAD:''' Coronary artery disease;
'''CBC:''' Complete blood count;
'''CCB:''' Calcium channel blocker;
'''CT:''' Computed tomography;
'''CXR:''' Chest x-ray;
'''DM:''' Diabetes mellitus;
'''EKG:''' Electrocardiogram;
'''HTN:''' Hypertension;
'''LVEF:''' Left ventricular ejection fraction;
'''LVH:''' Left ventricular hypertrophy;
'''MI:''' Myocardial infarction;
'''MRI:''' Magnetic resonance imaging;
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' Oral contraceptive pills;
'''PAWP:''' Pulmonary artery wedge pressure
'''TSH:''' Thyroid stimulating hormone
 

{{familytree/start}}
{{familytree | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
'''Symptoms of fluid accumulation:''' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
'''Symptoms of reduced cardiac output:''' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (may be suggestive of [[mesenteric ischemia]]) 
'''Symptoms suggestive of precipitating events:''' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitation]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
'''Nonspecific symptoms:''' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
'''Obtain a detailed history:''' 
❑ '''Past medical history:''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history:''' 
:❑ Noncompliance with medications 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s 
::❑ [[Thiazolidinedione]] 
❑ '''Family history:''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 
'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying infection) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] 
'''Assess weight:''' 
:❑ Subtract 'dry weight' from value to assess [[edema]] 
'''Skin:''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] 
'''Respiratory examination:''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 
'''Cardiovascular examination:''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (when right ventricular pressure is increased) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 
'''Abdominal examination:''' 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 
'''Extremity examination:''' 
❑ [[Pedal edema]] 
'''Neurological examination:''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | Q01 | |Q01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref> 
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] 
:❑ [[BUN]], [[creatinine]] 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 35 pg/mL 
:❑ NT-pro BNP ≤ 125 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ Cephalization
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior MI) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] (LBBB) 
:❑ [[Left atrial enlargement]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes 
❑ 2-D [[echocardiography]] with doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess LVEF and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] - in [[respiratory distress]] or [[shock]] 
'''Additional tests to rule out other etiologies:''' 
----
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
----
{{familytree | | | | | |!| | |}}
{{familytree | | | | | Y01 | |Y01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[COPD]]</td><td>❑ [[Dyspnea]], [[cough]], [[sputum]], history of smoking ❑ [[Spirometry]] reveals obstructive pattern</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ CXR - [[Pneumonia chest x ray|consolidation]]</td></tr>
<tr><td> [[Liver cirrhosis]]</td><td>❑ [[Jaundice]], [[fatigue]], [[peripheral edema]], [[coagulopathy]] ❑ Abnormal [[liver function tests]] ❑ [[Liver biopsy]] confirms the underlying cause</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors - trauma, immobilization, smoking, OCPs ❑ CT pulmonary angiography - clot in pulmonary artery</td></tr>
<tr><td>[[Peripartum cardiomyopathy]] </td><td>❑ [[Dyspnea]], [[orthopnea]], [[PND]] ❑ [[Pregnancy]] ❑ Absence of heart disease prior to onset of heart failure ❑ [[Echocardiography]] confirms [[left ventricular enlargement]] and [[systolic dysfunction]]</td></tr>
<tr><td>[[Nephrotic syndrome]] </td><td>❑ [[Dyspnea]], [[fatigue]], [[peripheral edema]] ❑ [[Urinalysis]] reveals [[proteinuria]] > 3.5g/24 hours</td></tr>
</table></div>}}
{{familytree/end}}

==Treatment==
{{familytree/start}}
{{familytree | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | C01 | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status''' 
❑ [[Congestion|Congestion at rest]] e.g., [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]] 
❑ Low perfusion at rest e.g., [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | Z01 | | | |Z01='''Classify the patient based on the left ventricular ejection fraction'''}}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01='''Systolic heart failure LVEF ≤ 40%'''|D02='''Diastolic heart failure LVEF ≥ 50%'''}}
{{familytree | | | |!| | | |}}
{{familytree | | | E01 | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''First step: Diuresis''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>
}}
{{familytree | | | |!| | | |}}
{{familytree | | | F01 | | |F01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Second step: ACE Inhibition and Angiotensin Receptor Blockade''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>
}}
{{familytree | | | |!| | |}}
{{familytree | | | G01 | |G01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Third step: Beta blockers''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree | | | |!| | |}}
{{familytree | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Fourth step: Aldosterone Antagonism''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree | | | |!| | |}}
{{familytree | | | I01 | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Fifth step: The Combination of Hydralazine and a Nitrate''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree | | | |!| | |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Sixth step: Digoxin''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

==== Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Ensure guideline-directed medical therapy (GDMT) - This is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible if no recent one available or if the patient's clinical status is deteriorating.
* Digitalis decreases hospitalization but not mortality. It can be beneficial in symptomatic patients with low EF.<ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an
episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* Make sure your patient is on [[DVT]] prophylaxis unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

Advanced heart failure refers to severe symptoms of heart failure with [[dyspnea]] and/or [[fatigue]] at rest or with minimal exertion (NYHA class III or IV). These parameters assist in identifying patients with advanced heart failure:
<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref>

* Repeated (≥2) hospitalizations or ED visits for HF in the past year
* Progressive deterioration in renal function (eg, rise in BUN and [[creatinine]])
* Weight loss without other cause (eg, cardiac cachexia)
* Intolerance to ACE inhibitors due to [[hypotension]] and/or worsening renal function
* Intolerance to beta blockers due to worsening HF or hypotension
* Frequent systolic blood pressure <90 mm Hg
* Persistent [[dyspnea]] with dressing or bathing requiring rest
* Inability to walk 1 block on the level ground due to dyspnea or fatigue
* Recent need to escalate diuretics to maintain volume status, often reaching daily [[furosemide]] equivalent dose over 160 mg/d and/or use of supplemental [[metolazone]] therapy
* Progressive decline in serum sodium, usually to < 133 mEq/L
* Frequent ICD shocks

==Don'ts==
* Avoid the use of [[NSAIDs]], sympathomimetics, [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine calcium channel blockers ([[diltiazem]], [[verapamil]].<ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't Use parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal functions worsening and hyperkalemia.
* Avoid using [[statins]] solely for [[heart failure]]. It adds no benefit.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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Chronic heart failure resident survival guide

2014-05-09T16:41:14Z

Ayokunle Olubaniyi: /* Diuretic Therapy */

<div style="width: 80%;">
__NOTOC__
{{CMG}}; {{AE}} {{AO}}
{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
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! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Chronic Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Diagnosis|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Treatment|Treatment]]
:[[Chronic heart failure resident survival guide#Diuretic Therapy|Diuretic Therapy]]
:[[Chronic heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
There are several goals in the chronic management of systolic [[heart failure]]. One goal of therapy is to improve the patient's symptoms, exercise tolerance and quality of life. [[Diuretics]], along with regular assessment of the patient's weight, minimizes fluid accumulation and the accompanying symptoms of [[dyspnea]] and [[orthopnea]]. Another goal is to reduce hospitalization and mortality. To achieve the second goal, patients with chronic [[heart failure]] should be administered an [[ACE inhibitor]] (or [[ARB]] if they are [[ACE]] intolerant) and a [[beta blocker]]. If the patient remains symptomatic, additional therapy may include an [[aldosterone antagonist]].

====Goals of Therapy====
{|class="wikitable"
! Goals!!Therapeutic intervention
|-
| To alleviate symptoms and signs||[[Diuretics]], [[morphine]] (no mortality benefit)
|-
| To reduce mortality||[[ACE inhibitors]]<ref name="pmid2883575">{{cite journal| author=| title=Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group. | journal=N Engl J Med | year= 1987 | volume= 316 | issue= 23 | pages= 1429-35 | pmid=2883575 | doi=10.1056/NEJM198706043162301 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2883575 }} </ref><ref name="pmid7654275">{{cite journal| author=Garg R, Yusuf S| title=Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. | journal=JAMA | year= 1995 | volume= 273 | issue= 18 | pages= 1450-6 | pmid=7654275 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7654275 }} </ref>, [[ARBs]], [[beta blockers]]<ref name="pmid11851582">{{cite journal| author=Foody JM, Farrell MH, Krumholz HM| title=beta-Blocker therapy in heart failure: scientific review. | journal=JAMA | year= 2002 | volume= 287 | issue= 7 | pages= 883-9 | pmid=11851582 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11851582 }} </ref>, [[aldosterone antagonists]]<ref name="pmid21073363">{{cite journal| author=Zannad F, McMurray JJ, Krum H, van Veldhuisen DJ, Swedberg K, Shi H et al.| title=Eplerenone in patients with systolic heart failure and mild symptoms. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 1 | pages= 11-21 | pmid=21073363 | doi=10.1056/NEJMoa1009492 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21073363 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21814643 Review in: J Fam Pract. 2011 Aug;60(8):482-4] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21558564 Review in: Evid Based Med. 2011 Aug;16(4):121-2] </ref>, [[hydralazine]] plus [[isosorbide dinitrate]]<ref name="pmid2057035">{{cite journal| author=Cohn JN, Johnson G, Ziesche S, Cobb F, Francis G, Tristani F et al.| title=A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. | journal=N Engl J Med | year= 1991 | volume= 325 | issue= 5 | pages= 303-10 | pmid=2057035 | doi=10.1056/NEJM199108013250502 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2057035 }} </ref>, [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref><ref name="pmid16087142">{{cite journal| author=Macchia A, Levantesi G, Franzosi MG, Geraci E, Maggioni AP, Marfisi R et al.| title=Left ventricular systolic dysfunction, total mortality, and sudden death in patients with myocardial infarction treated with n-3 polyunsaturated fatty acids. | journal=Eur J Heart Fail | year= 2005 | volume= 7 | issue= 5 | pages= 904-9 | pmid=16087142 | doi=10.1016/j.ejheart.2005.04.008 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16087142 }} </ref>, [[Cardiac resynchronization therapy|CRT]]<ref name="pmid15753115">{{cite journal| author=Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L et al.| title=The effect of cardiac resynchronization on morbidity and mortality in heart failure. | journal=N Engl J Med | year= 2005 | volume= 352 | issue= 15 | pages= 1539-49 | pmid=15753115 | doi=10.1056/NEJMoa050496 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15753115 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16134903 Review in: ACP J Club. 2005 Sep-Oct;143(2):29] </ref>, [[Implantable cardioverter defibrillator|ICD]]<ref name="pmid15659722">{{cite journal| author=Bardy GH, Lee KL, Mark DB, Poole JE, Packer DL, Boineau R et al.| title=Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. | journal=N Engl J Med | year= 2005 | volume= 352 | issue= 3 | pages= 225-37 | pmid=15659722 | doi=10.1056/NEJMoa043399 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15659722 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15989294 Review in: ACP J Club. 2005 Jul-Aug;143(1):6] </ref>
|-
| To reduce hospitalization||[[Digoxin]]<ref name="pmid9036306">{{cite journal| author=Digitalis Investigation Group| title=The effect of digoxin on mortality and morbidity in patients with heart failure. | journal=N Engl J Med | year= 1997 | volume= 336 | issue= 8 | pages= 525-33 | pmid=9036306 | doi=10.1056/NEJM199702203360801 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9036306 }} </ref>, [[ARBs]] (in [[Diastolic dysfunction|HFpEF]])<ref name="pmid13678871">{{cite journal| author=Yusuf S, Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ et al.| title=Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial. | journal=Lancet | year= 2003 | volume= 362 | issue= 9386 | pages= 777-81 | pmid=13678871 | doi=10.1016/S0140-6736(03)14285-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13678871 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15122853 Review in: ACP J Club. 2004 Mar-Apr;140(2):32-3] </ref>
|}

==Classification==
====Based on the Stage of Heart Failure====
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

====Based on the Severity of Congestive Heart Failure====
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Chronic heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.

===Common Causes===
* Cardiotoxic drugs (e.g. [[NSAIDs]], [[thiazolidinedione]], and certain [[chemotherapy]] drugs)
* [[Sepsis|Concurrent infections]] e.g., [[pneumonia]], viral illnesses
* Electrolyte imbalances
* Endocrine abnormalities - [[diabetes mellitus]], thyroid disorders ([[hyperthyroidism]], [[hypothyroidism]])
* Excessive [[alcohol]] or illicit drug use (e.g. [[cocaine]])
* Medication noncompliance
* [[Myocardial ischemia]] or [[infarction]]
* Noncompliance with dietary restrictions (e.g., sodium and fluid restriction)
* Progressive valvular disease (e.g. [[mitral regurgitation]])
* [[Pulmonary embolus]]
* [[Cardiac arrhythmias|Uncontrolled arrhythmias]]
* [[Hypertension|Uncontrolled hypertension]]

==Complete Diagnostic Approach==
The algorithm below describes the diagnostic approach to a patient with chronic heart failure.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' Acute respiratory distress syndrome;
'''BNP:''' B-type natriuretic peptide;
'''BUN:''' Blood urea nitrogen;
'''CAD:''' Coronary artery disease;
'''CBC:''' Complete blood count;
'''CCB:''' Calcium channel blocker;
'''CT:''' Computed tomography;
'''CXR:''' Chest x-ray;
'''DM:''' Diabetes mellitus;
'''EKG:''' Electrocardiogram;
'''HTN:''' Hypertension;
'''LVEF:''' Left ventricular ejection fraction;
'''LVH:''' Left ventricular hypertrophy;
'''MI:''' Myocardial infarction;
'''MRI:''' Magnetic resonance imaging;
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' Oral contraceptive pills;
'''PAWP:''' Pulmonary artery wedge pressure
'''TSH:''' Thyroid stimulating hormone
 

{{familytree/start}}
{{familytree | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
'''Symptoms of fluid accumulation:''' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
'''Symptoms of reduced cardiac output:''' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (may be suggestive of [[mesenteric ischemia]]) 
'''Symptoms suggestive of precipitating events:''' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitation]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
'''Nonspecific symptoms:''' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
'''Obtain a detailed history:''' 
❑ '''Past medical history:''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history:''' 
:❑ Noncompliance with medications 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s 
::❑ [[Thiazolidinedione]] 
❑ '''Family history:''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 
'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying infection) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] 
'''Assess weight:''' 
:❑ Subtract 'dry weight' from value to assess [[edema]] 
'''Skin:''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] 
'''Respiratory examination:''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 
'''Cardiovascular examination:''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (when right ventricular pressure is increased) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 
'''Abdominal examination:''' 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 
'''Extremity examination:''' 
❑ [[Pedal edema]] 
'''Neurological examination:''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | Q01 | |Q01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref> 
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] 
:❑ [[BUN]], [[creatinine]] 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 35 pg/mL 
:❑ NT-pro BNP ≤ 125 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ Cephalization
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior MI) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] (LBBB) 
:❑ [[Left atrial enlargement]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes 
❑ 2-D [[echocardiography]] with doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess LVEF and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] - in [[respiratory distress]] or [[shock]] 
'''Additional tests to rule out other etiologies:''' 
----
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
----
{{familytree | | | | | |!| | |}}
{{familytree | | | | | Y01 | |Y01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[COPD]]</td><td>❑ [[Dyspnea]], [[cough]], [[sputum]], history of smoking ❑ [[Spirometry]] reveals obstructive pattern</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ CXR - [[Pneumonia chest x ray|consolidation]]</td></tr>
<tr><td> [[Liver cirrhosis]]</td><td>❑ [[Jaundice]], [[fatigue]], [[peripheral edema]], [[coagulopathy]] ❑ Abnormal [[liver function tests]] ❑ [[Liver biopsy]] confirms the underlying cause</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors - trauma, immobilization, smoking, OCPs ❑ CT pulmonary angiography - clot in pulmonary artery</td></tr>
<tr><td>[[Peripartum cardiomyopathy]] </td><td>❑ [[Dyspnea]], [[orthopnea]], [[PND]] ❑ [[Pregnancy]] ❑ Absence of heart disease prior to onset of heart failure ❑ [[Echocardiography]] confirms [[left ventricular enlargement]] and [[systolic dysfunction]]</td></tr>
<tr><td>[[Nephrotic syndrome]] </td><td>❑ [[Dyspnea]], [[fatigue]], [[peripheral edema]] ❑ [[Urinalysis]] reveals [[proteinuria]] > 3.5g/24 hours</td></tr>
</table></div>}}
{{familytree/end}}

==Treatment==
{{familytree/start}}
{{familytree | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | C01 | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status''' 
❑ [[Congestion|Congestion at rest]] e.g., [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]] 
❑ Low perfusion at rest e.g., [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | Z01 | | | |Z01='''Classify the patient based on the left ventricular ejection fraction'''}}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01='''Systolic heart failure LVEF ≤ 40%'''|D02='''Diastolic heart failure LVEF ≥ 50%'''}}
{{familytree | | | |!| | | |}}
{{familytree | | | E01 | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''First step: Diuresis''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>
}}
{{familytree | | | |!| | | |}}
{{familytree | | | F01 | | |F01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Second step: ACE Inhibition and Angiotensin Receptor Blockade''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>
}}
{{familytree | | | |!| | |}}
{{familytree | | | G01 | |G01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Third step: Beta blockers''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree | | | |!| | |}}
{{familytree | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Fourth step: Aldosterone Antagonism''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree | | | |!| | |}}
{{familytree | | | I01 | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Fifth step: The Combination of Hydralazine and a Nitrate''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree | | | |!| | |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Sixth step: Digoxin''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

==== Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily doses, maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice, 600 mg max daily dose In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice, 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once, 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice, 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice, 200 mg
|-
| || [[Metolazone]] || 2.5 mg once, 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once, 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once, 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice, 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice, 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once, 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once, 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once, 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice, 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once, 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice, 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once, 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once, 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once, 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated, max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated, max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion, maximum of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily, 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily
|}

==Do's==
* Ensure guideline-directed medical therapy (GDMT) - This is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible if no recent one available or if the patient's clinical status is deteriorating.
* Digitalis decreases hospitalization but not mortality. It can be beneficial in symptomatic patients with low EF.<ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an
episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* Make sure your patient is on [[DVT]] prophylaxis unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

Advanced heart failure refers to severe symptoms of heart failure with [[dyspnea]] and/or [[fatigue]] at rest or with minimal exertion (NYHA class III or IV). These parameters assist in identifying patients with advanced heart failure:
<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref>

* Repeated (≥2) hospitalizations or ED visits for HF in the past year
* Progressive deterioration in renal function (eg, rise in BUN and [[creatinine]])
* Weight loss without other cause (eg, cardiac cachexia)
* Intolerance to ACE inhibitors due to [[hypotension]] and/or worsening renal function
* Intolerance to beta blockers due to worsening HF or hypotension
* Frequent systolic blood pressure <90 mm Hg
* Persistent [[dyspnea]] with dressing or bathing requiring rest
* Inability to walk 1 block on the level ground due to dyspnea or fatigue
* Recent need to escalate diuretics to maintain volume status, often reaching daily [[furosemide]] equivalent dose over 160 mg/d and/or use of supplemental [[metolazone]] therapy
* Progressive decline in serum sodium, usually to < 133 mEq/L
* Frequent ICD shocks

==Don'ts==
* Avoid the use of [[NSAIDs]], sympathomimetics, [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine calcium channel blockers ([[diltiazem]], [[verapamil]].<ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't Use parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal functions worsening and hyperkalemia.
* Avoid using [[statins]] solely for [[heart failure]]. It adds no benefit.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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[[Category:Resident survival guide]]
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Chronic heart failure resident survival guide

2014-05-09T16:32:58Z

Ayokunle Olubaniyi: /* Treatment */

<div style="width: 80%;">
__NOTOC__
{{CMG}}; {{AE}} {{AO}}
{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
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! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Chronic Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Diagnosis|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Treatment|Treatment]]
:[[Chronic heart failure resident survival guide#Diuretic Therapy|Diuretic Therapy]]
:[[Chronic heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
There are several goals in the chronic management of systolic [[heart failure]]. One goal of therapy is to improve the patient's symptoms, exercise tolerance and quality of life. [[Diuretics]], along with regular assessment of the patient's weight, minimizes fluid accumulation and the accompanying symptoms of [[dyspnea]] and [[orthopnea]]. Another goal is to reduce hospitalization and mortality. To achieve the second goal, patients with chronic [[heart failure]] should be administered an [[ACE inhibitor]] (or [[ARB]] if they are [[ACE]] intolerant) and a [[beta blocker]]. If the patient remains symptomatic, additional therapy may include an [[aldosterone antagonist]].

====Goals of Therapy====
{|class="wikitable"
! Goals!!Therapeutic intervention
|-
| To alleviate symptoms and signs||[[Diuretics]], [[morphine]] (no mortality benefit)
|-
| To reduce mortality||[[ACE inhibitors]]<ref name="pmid2883575">{{cite journal| author=| title=Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group. | journal=N Engl J Med | year= 1987 | volume= 316 | issue= 23 | pages= 1429-35 | pmid=2883575 | doi=10.1056/NEJM198706043162301 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2883575 }} </ref><ref name="pmid7654275">{{cite journal| author=Garg R, Yusuf S| title=Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. | journal=JAMA | year= 1995 | volume= 273 | issue= 18 | pages= 1450-6 | pmid=7654275 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7654275 }} </ref>, [[ARBs]], [[beta blockers]]<ref name="pmid11851582">{{cite journal| author=Foody JM, Farrell MH, Krumholz HM| title=beta-Blocker therapy in heart failure: scientific review. | journal=JAMA | year= 2002 | volume= 287 | issue= 7 | pages= 883-9 | pmid=11851582 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11851582 }} </ref>, [[aldosterone antagonists]]<ref name="pmid21073363">{{cite journal| author=Zannad F, McMurray JJ, Krum H, van Veldhuisen DJ, Swedberg K, Shi H et al.| title=Eplerenone in patients with systolic heart failure and mild symptoms. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 1 | pages= 11-21 | pmid=21073363 | doi=10.1056/NEJMoa1009492 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21073363 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21814643 Review in: J Fam Pract. 2011 Aug;60(8):482-4] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21558564 Review in: Evid Based Med. 2011 Aug;16(4):121-2] </ref>, [[hydralazine]] plus [[isosorbide dinitrate]]<ref name="pmid2057035">{{cite journal| author=Cohn JN, Johnson G, Ziesche S, Cobb F, Francis G, Tristani F et al.| title=A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. | journal=N Engl J Med | year= 1991 | volume= 325 | issue= 5 | pages= 303-10 | pmid=2057035 | doi=10.1056/NEJM199108013250502 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2057035 }} </ref>, [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref><ref name="pmid16087142">{{cite journal| author=Macchia A, Levantesi G, Franzosi MG, Geraci E, Maggioni AP, Marfisi R et al.| title=Left ventricular systolic dysfunction, total mortality, and sudden death in patients with myocardial infarction treated with n-3 polyunsaturated fatty acids. | journal=Eur J Heart Fail | year= 2005 | volume= 7 | issue= 5 | pages= 904-9 | pmid=16087142 | doi=10.1016/j.ejheart.2005.04.008 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16087142 }} </ref>, [[Cardiac resynchronization therapy|CRT]]<ref name="pmid15753115">{{cite journal| author=Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L et al.| title=The effect of cardiac resynchronization on morbidity and mortality in heart failure. | journal=N Engl J Med | year= 2005 | volume= 352 | issue= 15 | pages= 1539-49 | pmid=15753115 | doi=10.1056/NEJMoa050496 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15753115 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16134903 Review in: ACP J Club. 2005 Sep-Oct;143(2):29] </ref>, [[Implantable cardioverter defibrillator|ICD]]<ref name="pmid15659722">{{cite journal| author=Bardy GH, Lee KL, Mark DB, Poole JE, Packer DL, Boineau R et al.| title=Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. | journal=N Engl J Med | year= 2005 | volume= 352 | issue= 3 | pages= 225-37 | pmid=15659722 | doi=10.1056/NEJMoa043399 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15659722 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15989294 Review in: ACP J Club. 2005 Jul-Aug;143(1):6] </ref>
|-
| To reduce hospitalization||[[Digoxin]]<ref name="pmid9036306">{{cite journal| author=Digitalis Investigation Group| title=The effect of digoxin on mortality and morbidity in patients with heart failure. | journal=N Engl J Med | year= 1997 | volume= 336 | issue= 8 | pages= 525-33 | pmid=9036306 | doi=10.1056/NEJM199702203360801 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9036306 }} </ref>, [[ARBs]] (in [[Diastolic dysfunction|HFpEF]])<ref name="pmid13678871">{{cite journal| author=Yusuf S, Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ et al.| title=Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial. | journal=Lancet | year= 2003 | volume= 362 | issue= 9386 | pages= 777-81 | pmid=13678871 | doi=10.1016/S0140-6736(03)14285-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13678871 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15122853 Review in: ACP J Club. 2004 Mar-Apr;140(2):32-3] </ref>
|}

==Classification==
====Based on the Stage of Heart Failure====
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

====Based on the Severity of Congestive Heart Failure====
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Chronic heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.

===Common Causes===
* Cardiotoxic drugs (e.g. [[NSAIDs]], [[thiazolidinedione]], and certain [[chemotherapy]] drugs)
* [[Sepsis|Concurrent infections]] e.g., [[pneumonia]], viral illnesses
* Electrolyte imbalances
* Endocrine abnormalities - [[diabetes mellitus]], thyroid disorders ([[hyperthyroidism]], [[hypothyroidism]])
* Excessive [[alcohol]] or illicit drug use (e.g. [[cocaine]])
* Medication noncompliance
* [[Myocardial ischemia]] or [[infarction]]
* Noncompliance with dietary restrictions (e.g., sodium and fluid restriction)
* Progressive valvular disease (e.g. [[mitral regurgitation]])
* [[Pulmonary embolus]]
* [[Cardiac arrhythmias|Uncontrolled arrhythmias]]
* [[Hypertension|Uncontrolled hypertension]]

==Complete Diagnostic Approach==
The algorithm below describes the diagnostic approach to a patient with chronic heart failure.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' Acute respiratory distress syndrome;
'''BNP:''' B-type natriuretic peptide;
'''BUN:''' Blood urea nitrogen;
'''CAD:''' Coronary artery disease;
'''CBC:''' Complete blood count;
'''CCB:''' Calcium channel blocker;
'''CT:''' Computed tomography;
'''CXR:''' Chest x-ray;
'''DM:''' Diabetes mellitus;
'''EKG:''' Electrocardiogram;
'''HTN:''' Hypertension;
'''LVEF:''' Left ventricular ejection fraction;
'''LVH:''' Left ventricular hypertrophy;
'''MI:''' Myocardial infarction;
'''MRI:''' Magnetic resonance imaging;
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' Oral contraceptive pills;
'''PAWP:''' Pulmonary artery wedge pressure
'''TSH:''' Thyroid stimulating hormone
 

{{familytree/start}}
{{familytree | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
'''Symptoms of fluid accumulation:''' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
'''Symptoms of reduced cardiac output:''' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (may be suggestive of [[mesenteric ischemia]]) 
'''Symptoms suggestive of precipitating events:''' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitation]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
'''Nonspecific symptoms:''' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
'''Obtain a detailed history:''' 
❑ '''Past medical history:''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history:''' 
:❑ Noncompliance with medications 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s 
::❑ [[Thiazolidinedione]] 
❑ '''Family history:''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 
'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying infection) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] 
'''Assess weight:''' 
:❑ Subtract 'dry weight' from value to assess [[edema]] 
'''Skin:''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] 
'''Respiratory examination:''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 
'''Cardiovascular examination:''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (when right ventricular pressure is increased) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 
'''Abdominal examination:''' 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 
'''Extremity examination:''' 
❑ [[Pedal edema]] 
'''Neurological examination:''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | Q01 | |Q01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref> 
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] 
:❑ [[BUN]], [[creatinine]] 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 35 pg/mL 
:❑ NT-pro BNP ≤ 125 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ Cephalization
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior MI) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] (LBBB) 
:❑ [[Left atrial enlargement]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes 
❑ 2-D [[echocardiography]] with doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess LVEF and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] - in [[respiratory distress]] or [[shock]] 
'''Additional tests to rule out other etiologies:''' 
----
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
----
{{familytree | | | | | |!| | |}}
{{familytree | | | | | Y01 | |Y01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[COPD]]</td><td>❑ [[Dyspnea]], [[cough]], [[sputum]], history of smoking ❑ [[Spirometry]] reveals obstructive pattern</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ CXR - [[Pneumonia chest x ray|consolidation]]</td></tr>
<tr><td> [[Liver cirrhosis]]</td><td>❑ [[Jaundice]], [[fatigue]], [[peripheral edema]], [[coagulopathy]] ❑ Abnormal [[liver function tests]] ❑ [[Liver biopsy]] confirms the underlying cause</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors - trauma, immobilization, smoking, OCPs ❑ CT pulmonary angiography - clot in pulmonary artery</td></tr>
<tr><td>[[Peripartum cardiomyopathy]] </td><td>❑ [[Dyspnea]], [[orthopnea]], [[PND]] ❑ [[Pregnancy]] ❑ Absence of heart disease prior to onset of heart failure ❑ [[Echocardiography]] confirms [[left ventricular enlargement]] and [[systolic dysfunction]]</td></tr>
<tr><td>[[Nephrotic syndrome]] </td><td>❑ [[Dyspnea]], [[fatigue]], [[peripheral edema]] ❑ [[Urinalysis]] reveals [[proteinuria]] > 3.5g/24 hours</td></tr>
</table></div>}}
{{familytree/end}}

==Treatment==
{{familytree/start}}
{{familytree | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | C01 | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status''' 
❑ [[Congestion|Congestion at rest]] e.g., [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]] 
❑ Low perfusion at rest e.g., [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | Z01 | | | |Z01='''Classify the patient based on the left ventricular ejection fraction'''}}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01='''Systolic heart failure LVEF ≤ 40%'''|D02='''Diastolic heart failure LVEF ≥ 50%'''}}
{{familytree | | | |!| | | |}}
{{familytree | | | E01 | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''First step: Diuresis''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>
}}
{{familytree | | | |!| | | |}}
{{familytree | | | F01 | | |F01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Second step: ACE Inhibition and Angiotensin Receptor Blockade''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>
}}
{{familytree | | | |!| | |}}
{{familytree | | | G01 | |G01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Third step: Beta blockers''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree | | | |!| | |}}
{{familytree | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Fourth step: Aldosterone Antagonism''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree | | | |!| | |}}
{{familytree | | | I01 | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Fifth step: The Combination of Hydralazine and a Nitrate''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree | | | |!| | |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Sixth step: Digoxin''' 
----
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree/end}}

====Diuretic Therapy====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Commence IV [[diuretics]] 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients</div> 
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 

----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ DVT prophylaxis</div>}}
{{familytree/end}}

==== Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily doses, maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice, 600 mg max daily dose In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice, 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once, 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice, 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice, 200 mg
|-
| || [[Metolazone]] || 2.5 mg once, 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once, 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once, 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice, 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice, 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once, 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once, 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once, 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice, 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once, 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice, 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once, 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once, 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once, 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated, max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated, max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion, maximum of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily, 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily
|}

==Do's==
* Ensure guideline-directed medical therapy (GDMT) - This is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible if no recent one available or if the patient's clinical status is deteriorating.
* Digitalis decreases hospitalization but not mortality. It can be beneficial in symptomatic patients with low EF.<ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an
episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* Make sure your patient is on [[DVT]] prophylaxis unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

Advanced heart failure refers to severe symptoms of heart failure with [[dyspnea]] and/or [[fatigue]] at rest or with minimal exertion (NYHA class III or IV). These parameters assist in identifying patients with advanced heart failure:
<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref>

* Repeated (≥2) hospitalizations or ED visits for HF in the past year
* Progressive deterioration in renal function (eg, rise in BUN and [[creatinine]])
* Weight loss without other cause (eg, cardiac cachexia)
* Intolerance to ACE inhibitors due to [[hypotension]] and/or worsening renal function
* Intolerance to beta blockers due to worsening HF or hypotension
* Frequent systolic blood pressure <90 mm Hg
* Persistent [[dyspnea]] with dressing or bathing requiring rest
* Inability to walk 1 block on the level ground due to dyspnea or fatigue
* Recent need to escalate diuretics to maintain volume status, often reaching daily [[furosemide]] equivalent dose over 160 mg/d and/or use of supplemental [[metolazone]] therapy
* Progressive decline in serum sodium, usually to < 133 mEq/L
* Frequent ICD shocks

==Don'ts==
* Avoid the use of [[NSAIDs]], sympathomimetics, [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine calcium channel blockers ([[diltiazem]], [[verapamil]].<ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't Use parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal functions worsening and hyperkalemia.
* Avoid using [[statins]] solely for [[heart failure]]. It adds no benefit.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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2014-05-09T16:09:31Z

Ayokunle Olubaniyi: /* Underlying Anatomic Abnormalities Causing Heart Failure */

==CHF==

{{familytree/start}}
{{familytree | | | |!| | | |!| | |}}
{{familytree | | | E01 |~| E02 | |E01=[[Chronic heart failure resident survival guide#Diuretic Therapy|Diuretic therapy]]|E02= [[ACE inhibitors]] '''AND''' [[Beta blockers]]}}
{{familytree | | | | | | | |!| |}}
{{familytree | | | | | | | F01 | |F01=Intolerant to ACE-I}}
{{familytree | | | | | |,|-|^|-|.| |}}
{{familytree | | | | | G01 | | G02 | |G01=[[Cough]]|G02=[[Renal insufficiency]] or [[angioedema]]}}
{{familytree | | | | | |!| | | |!| |}}
{{familytree | | | | | H01 | | H02 | |H01=[[Angiotensin II receptor antagonist|ARBs]]|H02=[[Hydralazine]]/[[isosorbide dinitrate]]<ref name="pmid3520315">{{cite journal| author=Cohn JN, Archibald DG, Ziesche S, Franciosa JA, Harston WE, Tristani FE et al.| title=Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative Study. | journal=N Engl J Med | year= 1986 | volume= 314 | issue= 24 | pages= 1547-52 | pmid=3520315 | doi=10.1056/NEJM198606123142404 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3520315 }} </ref>}}
{{familytree | | | | | |`|-|v|-|'| |}}
{{familytree | | | | | | | I01 | | | I01=Persistent symptoms?}}
{{familytree | | | | | |,|-|^|-|.| |}}
{{familytree | | | | | J01 | | J02 | J01='''Yes'''|J02='''No'''}}
{{familytree | | | | | |!| | | |!| | }}
{{familytree | | | | | K01 | | |!| | K01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Add:''' 
❑ [[Aldosterone]] or [[eplerenone]] if: 
:❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
:❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
:❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
:❑ NYHA class II–IV HF with LVEF ≤ 35% '''OR''' 
❑ [[Hydralazine]]/[[isosorbide dinitrate]] 
:❑ African Americans with NYHA class III–IV HFrEF on GDMT '''OR''' 
❑ [[ARBs]]<ref name="pmid13678868">{{cite journal| author=Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, Michelson EL et al.| title=Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme. | journal=Lancet | year= 2003 | volume= 362 | issue= 9386 | pages= 759-66 | pmid=13678868 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13678868 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15122853 Review in: ACP J Club. 2004 Mar-Apr;140(2):32-3] </ref>

</div>}}
{{familytree | | | | | |!| | | |!| | |}}
{{familytree | | | | | L01 | | |!| | |L01=Persistent symptoms?}}
{{familytree | | | | | |!| | | |!| |}}
{{familytree | | | | | M01 | | |!| |M01=Add [[digoxin]] }}
{{familytree | | | | | |!| | | |!| | |}}
{{familytree | | | | | N01 | | |!| | |N01=Persistent symptoms?}}
{{familytree | | | |,|-|^|-|.| |!| | }}
{{familytree | | | O01 | | O02 |!| | |O01='''Yes'''|O02='''No'''}}
{{familytree | | | |!| | | |`|-|^|-|.| | |}}
{{familytree | | | P01 | | | | | | P02 | | | | P01=<div style="float: left; text-align: left; width: 15em; padding:1em;">
❑ LVEF ≤ 35% 
❑ Sinus rhythm or [[Left bundle branch block|LBBB]] 
❑ [[Chronic heart failure resident survival guide#New York Heart Association (NYHA)|NYHA]] III - IV </div>|P02=LVEF ≤ 35%?}}
{{familytree | |,|-|^|-|.| | | |,|-|^|-|.| | |}}
{{familytree | Q01 | | Q02 | | Q03 | | Q04 | | |Q01='''Yes'''|Q02='''No'''|Q03='''Yes'''|Q04='''No'''}}
{{familytree | |!| | | |!| | | |!| | | |!| |}}
{{familytree | R01 | | |!| | | R02 | | R03 | |R01=[[Cardiac resynchronization therapy]] (CRT) ± [[Implantable cardioverter defibrillator]] (ICD)|R02=<div style="float: left; text-align: left; width: 15em; padding:1em;">[[Implantable cardioverter defibrillator]] 
❑ As primary prevention of [[sudden cardiac death]] in:
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT </div>|R03=Continue GDMT}}
{{familytree | |`|-|v|-|'| | |}}
{{familytree | | | S01 | | |S01=Persistent symptoms (Advanced heart failure)}}
{{familytree | | | |!| | |}}
{{familytree | | | T01 | |T01=IV inotropes or vasodilators }}
{{familytree | | | |!| | |}}
{{familytree | | | U01 | | U01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''[[Mechanical circulatory support]] (MCS)<ref name="pmid21300961">{{cite journal| author=Naidu SS| title=Novel percutaneous cardiac assist devices: the science of and indications for hemodynamic support. | journal=Circulation | year= 2011 | volume= 123 | issue= 5 | pages= 533-43 | pmid=21300961 | doi=10.1161/CIRCULATIONAHA.110.945055 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21300961 }} </ref>:''' 
* [[Intra-aortic balloon pump]] 
* [[Ventricular assist device|LVAD]] - as bridge to recovery,<ref name="pmid17079761">{{cite journal| author=Birks EJ, Tansley PD, Hardy J, George RS, Bowles CT, Burke M et al.| title=Left ventricular assist device and drug therapy for the reversal of heart failure. | journal=N Engl J Med | year= 2006 | volume= 355 | issue= 18 | pages= 1873-84 | pmid=17079761 | doi=10.1056/NEJMoa053063 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17079761 }} </ref> transplant, or as definitive therapy<ref name="pmid19920051">{{cite journal| author=Slaughter MS, Rogers JG, Milano CA, Russell SD, Conte JV, Feldman D et al.| title=Advanced heart failure treated with continuous-flow left ventricular assist device. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 23 | pages= 2241-51 | pmid=19920051 | doi=10.1056/NEJMoa0909938 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19920051 }} </ref> 
❑ General indications:
:❑ LVEF ≤ 25% 
:❑ NYHA III or IV on chronic GDMT 
:❑ Predicted 1-2 year mortality</div>|R03=Continue GDMT</div>}}
{{familytree | | | |!| |}}
{{familytree | | | V01 | V01=[[Heart transplantation|Cardiac transplantation]]}}
{{familytree/end}}

==Hypertension==
{{familytree/start}}
{{familytree | |,|-|-|-|v|-|-|^|-|-|v|-|-|-|.| | |}}
{{familytree | J01 | | J02 | | | | J03 |~| J04 | | |J01=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Dry''' 
----
❑ Consider outpatient treatment ❑ Dietary sodium restriction (2-3 g daily) ❑ [[Smoking cessation]] ❑ [[Alcohol]] abstinence (≤2 standard drinks per day for men; ≤1 for women) ❑ Encourage exercise/physical activity 
'''Although [[ACE inhibitors]] and [[beta blockers]] should not be administered to patients with [[acute decompensated heart failure]], if the patient is compensated in the outpatient setting then administer: ❑ [[ACE inhibitors]] or ([[ARBs]]) if LVEF is ≤ 40% ❑ [[Beta blockers]]'''<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> </div>|

J02=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Wet''' 
----
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] 
❑ Treat co-morbidities [[HTN]], [[DM]], [[CAD]], [[AF]]</div>|

J03=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Wet''' 
----
❑ CCU admission 
❑ Invasive hemodynamic monitoring (arterial line, consider pulmonary catheter if volume status unclear) 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) ❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] while monitoring [[blood pressure]] ❑ IV vasodilators</div>|J04=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Dry''' 
----
❑ CCU admission 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) 
❑ '''Persistent organ hypoperfusion''' (e.g., low urine output or persistent low SBP<85) 
:❑ [[Norepinephrine]] 0.2–1.0 mcg/kg/min, titrate to maintain a blood pressure of </div>}}
{{familytree | | | | | |!| | | | | |!| | | |!| | | | |}}
{{familytree | | | | | |`|-|-|v|-|-|^|-|-|-|'| | |}}
{{familytree | | | | | | | | X01 | | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | K01 | | | |K01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | | | | | |}}
{{familytree | | | | | | | | L01 | | | |L01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

==Underlying Anatomic Abnormalities Causing Heart Failure==
{{familytree/start}}
{{familytree | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | C01 | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status''' 
❑ [[Congestion|Congestion at rest]] e.g., [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]] 
❑ Low perfusion at rest e.g., [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | Z01 | | | |Z01='''Classify the patient based on the left ventricular ejection fraction'''}}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01='''Systolic heart failure LVEF ≤ 40%'''|D02='''Diastolic heart failure LVEF ≥ 50%'''}}
{{familytree/end}}

==Systolic versus Diastolic Heart Failure==
Patients may be broadly classified as having heart failure with depressed contractility or depressed relaxation
===Systolic Dysfunction===
The [[left ventricular ejection fraction]] is reduced in [[systolic dysfunction]] and there is depressed contractility of the heart.
===Disastolic Dysfunciton===
The [[left ventricular ejection fraction]] is preserved in [[diastolic dysfunction]] and there is an abnormality in myocardial relaxation or excessive myocardial stiffness. Systolic and diastolic dysfunction commonly occur in conjunction with each other.

==Left, Right and Biventricular Failure==
Another common method of classifying heart failure is based upon the ventricle involved (left sided versus right sided).
===Left Heart Failure===
*There is impaired left ventricular function with reduced flow into the aorta.
===Right Heart Failure===
*There is impaired right ventricular function with reduced flow into the pulmonary artery and lungs.
===Biventricular Failure===
*The most common cause of right heart failure is left heart failure, and mixed presentations are common, especially when the cardiac septum is involved.

==High Output Versus Low Output Failure==
===Low Output Failure===
*The [[cardiac output]] is reduced, and the [[systemic vascular resistance]] ([[SVR]]) is high. In low output failure, there is an inadequate supply of blood flow to meet normal metabolic demands.

===High Output Failure===
*The [[cardiac output]] is increased, and the [[systemic vascular resistance]] ([[SVR]]) is low. Rather than an inadequate supply of blood flow to meet normal metabolic demands as occurs in low output failure, in high output failure there is an excess requirement for oxygen and nutrients and the demand outstrips what the heart can provide.<ref>{{DorlandsDict|nine/000953450|high-output heart failure}}</ref> Causes of high output heart failure include severe [[anemia]], Gram negative [[septicaemia]], [[beriberi]] (vitamin B1/thiamine deficiency), [[thyrotoxicosis]], [[Paget's disease of bone|Paget's disease]], [[arteriovenous fistula]]e, or [[arteriovenous malformation]]s.

==Causes of Acute or Decompensated Heart Failure==
Chronic stable heart failure may easily decompensate. This most commonly results from an intercurrent illness (such as [[pneumonia]]), [[myocardial infarction]] (a heart attack), [[cardiac arrhythmia|arrhythmias]], uncontrolled [[hypertension]], or a patient's failure to maintain a fluid restriction, diet, or medication.<ref name="OPTIMIZE-HF">{{cite journal |author=Fonarow GC, Abraham WT, Albert NM, ''et al.'' |title=Factors Identified as Precipitating Hospital Admissions for Heart Failure and Clinical Outcomes: Findings From OPTIMIZE-HF |journal=Arch. Intern. Med. |volume=168 |issue=8 |pages=847–854 |year=2008 |month=April |pmid=18443260 |doi=10.1001/archinte.168.8.847}}</ref> Other well recognized precipitating factors include [[anemia]] and [[hyperthyroidism]] which place additional strain on the heart muscle. Excessive fluid or salt intake, and medication that causes fluid retention such as [[Non-steroidal anti-inflammatory drug|NSAIDs]] and [[thiazolidinedione]]s, may also precipitate decompensation.<ref>{{cite journal |author=Nieminen MS, Böhm M, Cowie MR, ''et al.'' |title=Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the Task Force on Acute Heart Failure of the European Society of Cardiology |journal=Eur. Heart J. |volume=26 |issue=4 |pages=384–416 |year=2005 |month=February |pmid=15681577 |doi=10.1093/eurheartj/ehi044 |url=http://eurheartj.oxfordjournals.org/cgi/content/full/26/4/384}}</ref>

==Differential Diagnosis of the Underlying Causes of Chronic Heart Failure==
===Common Causes of Left Sided Heart Failure===
* [[Aortic Regurgitation|Aortic regurgitation]]
* [[Aortic Stenosis|Aortic stenosis]]
* [[Hypertension]]
* [[Mitral Regurgitation|Mitral regurgitation]]
* [[Myocardial ischemia]]

A 19 year study of 13,000 healthy adults in the United States (the [[National Health and Nutrition Examination Survey]] (NHANES I) found the following causes ranked by Population Attributable Risk score:<ref>{{cite journal |author=He J; Ogden LG; Bazzano LA; Vupputuri S, ''et al.'' |title=Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study|journal=Arch. Intern. Med. |volume=161 |issue=7 |pages=996–1002|year=2001 |pmid= 11295963 |doi=10.1001/archinte.161.7.996 }}</ref>
#[[Ischaemic heart disease]] 62%
#[[Tobacco smoking|Cigarette smoking]] 16%
#[[Hypertension]] (high blood pressure)10%
#[[Obesity]] 8%
#[[Diabetes]] 3%
#[[Valvular heart disease]] 2% (much higher in older populations)

===Cardiomyopathies and Inflammatory Diseases===

=====[[Restrictive Cardiomyopathies]]=====
*[[Alcohol-Induced cardiomyopathy]]
*[[Amyloidosis]]
*[[Anthracycline induced cardiomyopathy]]
*[[Anthracyclines]]
*[[Arrhythmogenic right ventricular dysplasia]]
*[[Becker's muscular dystrophy]]
*[[Cardiac transplant]]
*[[Cocaine related cardiomyopathy]]
*[[Diabetic cardiomyopathy]]
*[[Endocardial fibrosis]]
*[[Eosinophilic heart disease]]
*[[Hemochromatosis]]
*Primary (idiopathic)
*[[Kearns-Sayre syndrome]]
*[[Radiation therapy]]
*[[Sarcoidosis]]
*Storage diseases
*[[Tumor]] infiltration

=====[[Dilated Cardiomyopathies]]=====
*[[Duchenne muscular dystrophy]]
*[[Chagas' disease]]
*[[Limb-girdle muscular dystrophy]]
*[[Mitochondrial myopathy]]
*[[Peripartum cardiomyopathy]]
*[[Trastuzumab]] [[Herceptin-lnduced Cardiomyopathy]]

=====Inflammatory Cardiomyopathies=====

*[[Bacterial Myocarditis]]
*[[Fungal myocarditis]]
*[[Giant Cell Myocarditis]]
*[[Myocarditis|Protozoal Myocarditis]]: [[Trypanosomiasis]] ([[Chagas Disease]])
*[[Rickettsial Myocarditis]]
*[[Sarcoidosis]]
*[[Spirochetal Infections]]
*[[Viral Myocarditis]]

===Congestive Heart Failure as a Consequence of Valvular Heart Disease===
*[[Acute aortic regurgitation]]
*[[Acute mitral regurgitation]]
*[[Aortic stenosis with Left Ventricular Systolic Dysfunction]]
*[[Chronic aortic regurgitation]]
*[[Chronic mitral regurgitation]]
*[[Mitral Stenosis]]

===Congestive Hert Failure Secondary to Congenital Heart Disease===

'''A. Causes of Congestive Heart Failure in Adults with Unoperated Congenital Heart Diseases'''
*[[Arrhythmia]]
*[[Atrial septal defect]] with [[mitral regurgitation]]] secondary to myxomatous mitral valve
*[[Congenital mitral regurgitation]]
*[[Drug abuse]], [[alcohol abuse]]
*[[Eisenmenger's syndrome]]
*[[Endocarditis]]
*Fibrocalcific degeneration of abnormal [[aortic valve]]
*[[Pregnancy]]
*Systemic ventricular dysfunction and/or [[tricuspid regurgitation]] in congenitally corrected transposition of the great arteries
*Other degenerative diseases ([[coronary artery disease]], [[hypertension]])
'''B. Causes of Congestive Heart Failure in Adults with Operated Congenital Heart Diseases'''
*[[Arrhythmia]]
*[[Endocarditis]]
*Myocardial dysfunction
*Persistent left-to-right shunt
*Prosthetic valve dysfunction
*Pulmonary vascular disease
*Status post [[Fontan operation]]
*Valvular regurgitation
*Other degenerative diseases ([[coronary artery disease]], [[hypertension]])

=== Right Ventricular Failure ===
Factors affected right ventricle and to be eliminated during management of congestive heart failure.
A. Right ventricular myocardial dysfunction
#[[Right ventricular myocardial infarction]]
#[[Dilated cardiomyopathy]]
#[[Arrhythmogenic right ventricular dysplasia|Right ventricular dysplasia]]
B. Primary right ventricular pressure overload
#[[Left ventricular failure]]
#[[Mitral valve]] disease
#[[Atrial myxoma]]
#[[Pulmonary veno-occlusive disease]]
#[[Cor pulmonale]]
#:*[[Chronic obstructive pulmonary disease]]
#:*[[Primary pulmonary hypertension]]
#:*[[Pulmonary embolism]]
#[[Pulmonic stenosis]]
#:*[[Supravalvular pulmonic stenosis]]
#:*[[Valvular pulmonic stenosis]]
#:*[[Subvalvular pulmonic stenosis]]
#[[Ventricular septal defect]]
#Aortopulmonary communication
C. Primary right ventricular volume overload
#[[Pulmonic regurgitation]]
#[[Tricuspid regurgitation]]
#[[Atrial septal defect]]
#[[Partial anomalous pulmonary venous return]]
D. Impediment to right ventricular inflow
#[[Tricuspid stenosis]]
#[[Cardiac tamponade]]
#[[pericarditis |Constrictive pericarditis]]
#[[cardiomyopathy|Restrictive cardiomyopathy]]

== Differential Diagnosis of Causes of Heart Failure Segregated by Left and Right Sided Heart Failure==
===Left Ventricular Failure===
====Most Common Causes:====
* [[Aortic Regurgitation|Aortic regurgitation]]
* [[Aortic Stenosis|Aortic stenosis]]
* [[Hypertension]]
* [[Mitral Regurgitation|Mitral regurgitation]]
* [[Myocardial ischemia]]

====Expanded List of Causes:====
* [[Atrial fibrillation]]
* [[Alcoholism]]
* [[Anemia]]
* [[Angina]]
* [[Aortic Regurgitation|Aortic regurgitation]]
* [[Aortic Stenosis]]
* [[Arteriovenous fistula]]
* [[Beriberi]]
* [[aneurysm|Cardiac aneurysm]]
* [[Cardiomyopathy]]
* [[pericarditis|Constrictive pericarditis]]
* [[Drugs]], [[toxin]]s
* [[Hypertension]]
* [[Hyperthyroidism]]
* [[Hypovolemia]]
* [[Hypoxia]]
* Mediastinal tumors
* [[Mitral Regurgitation]]
* [[Myocardial Infarction]]
* [[Paget's Disease]]
* [[Pancoast's Tumor]]
* [[Pericardial effusion]]
* [[Pericardial tamponade]]
* [[Perimyocarditis]]
* [[Protein deficiency]]
* [[Restrictive cardiomyopathy]]
* [[Papillary muscle rupture|Rupture of the papillary muscles]]
* [[Sepsis]]
* [[Superior Vena Cava]] thrombosis

===Right Ventricular Failure ===
====Most Common Causes:====
* [[Cardiomyopathy]]
* [[Cor pulmonale]]
* [[myocarditis|Diffuse myocarditis]]
* Left heart failure

====Other Causes:====
* After [[left ventricular failure]]
* After pulmonary resection
* [[Alveolitis|Allergic alveolitis]]
* [[asthma|Bronchial asthma]]
* [[bronchitis|Chronic bronchitis]]
* [[Alveolitis|Honeycomb lung]]
* [[Hyperglobulia]]
* [[Emphysema]]
* [[Mitral Stenosis]]
* [[Right ventricular myocardial infarction]]
* [[Pickwickian Syndrome]]
* Pleural fibrosis
* [[Pneumoconiosis]]
* [[Pulmonary fibrosis]]
* [[Pulmonic regurgitation]]
* [[Pulmonic stenosis]]
* [[Sarcoidosis]]
* [[pulmonary emboli|Severe relapsing pulmonary emboli]]
* [[Silicosis]]
* [[Tachycardia]]
* [[Tricuspid insufficiency]]

===Others===
* [[Ascorbic acid deficiency]]
* [[Cardiac amyloidosis]]
* [[Carnitine deficiency]]
* Cervical vein stasis of non-cardiac genesis
* [[Congenital heart disease]]
* [[Cyanosis]] of non-cardiac genesis
* [[Diabetes Mellitus]]
* [[Ddx:Dyspnea|Dyspnea]] of non-cardiac genesis
* [[Edema]] of non-cardiac genesis
* [[Hemochromatosis]]
* [[Pleural effusion]] of non-cardiac genesis
* [[Pulmonary edema]] of non-cardiac genesis
* [[Thiamine deficiency]]
* [[Thyroid disease]]

Sandbox/22

2014-05-09T16:02:12Z

Ayokunle Olubaniyi: /* CHF */

==CHF==

{{familytree/start}}
{{familytree | | | |!| | | |!| | |}}
{{familytree | | | E01 |~| E02 | |E01=[[Chronic heart failure resident survival guide#Diuretic Therapy|Diuretic therapy]]|E02= [[ACE inhibitors]] '''AND''' [[Beta blockers]]}}
{{familytree | | | | | | | |!| |}}
{{familytree | | | | | | | F01 | |F01=Intolerant to ACE-I}}
{{familytree | | | | | |,|-|^|-|.| |}}
{{familytree | | | | | G01 | | G02 | |G01=[[Cough]]|G02=[[Renal insufficiency]] or [[angioedema]]}}
{{familytree | | | | | |!| | | |!| |}}
{{familytree | | | | | H01 | | H02 | |H01=[[Angiotensin II receptor antagonist|ARBs]]|H02=[[Hydralazine]]/[[isosorbide dinitrate]]<ref name="pmid3520315">{{cite journal| author=Cohn JN, Archibald DG, Ziesche S, Franciosa JA, Harston WE, Tristani FE et al.| title=Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative Study. | journal=N Engl J Med | year= 1986 | volume= 314 | issue= 24 | pages= 1547-52 | pmid=3520315 | doi=10.1056/NEJM198606123142404 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3520315 }} </ref>}}
{{familytree | | | | | |`|-|v|-|'| |}}
{{familytree | | | | | | | I01 | | | I01=Persistent symptoms?}}
{{familytree | | | | | |,|-|^|-|.| |}}
{{familytree | | | | | J01 | | J02 | J01='''Yes'''|J02='''No'''}}
{{familytree | | | | | |!| | | |!| | }}
{{familytree | | | | | K01 | | |!| | K01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Add:''' 
❑ [[Aldosterone]] or [[eplerenone]] if: 
:❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
:❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
:❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
:❑ NYHA class II–IV HF with LVEF ≤ 35% '''OR''' 
❑ [[Hydralazine]]/[[isosorbide dinitrate]] 
:❑ African Americans with NYHA class III–IV HFrEF on GDMT '''OR''' 
❑ [[ARBs]]<ref name="pmid13678868">{{cite journal| author=Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, Michelson EL et al.| title=Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme. | journal=Lancet | year= 2003 | volume= 362 | issue= 9386 | pages= 759-66 | pmid=13678868 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13678868 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15122853 Review in: ACP J Club. 2004 Mar-Apr;140(2):32-3] </ref>

</div>}}
{{familytree | | | | | |!| | | |!| | |}}
{{familytree | | | | | L01 | | |!| | |L01=Persistent symptoms?}}
{{familytree | | | | | |!| | | |!| |}}
{{familytree | | | | | M01 | | |!| |M01=Add [[digoxin]] }}
{{familytree | | | | | |!| | | |!| | |}}
{{familytree | | | | | N01 | | |!| | |N01=Persistent symptoms?}}
{{familytree | | | |,|-|^|-|.| |!| | }}
{{familytree | | | O01 | | O02 |!| | |O01='''Yes'''|O02='''No'''}}
{{familytree | | | |!| | | |`|-|^|-|.| | |}}
{{familytree | | | P01 | | | | | | P02 | | | | P01=<div style="float: left; text-align: left; width: 15em; padding:1em;">
❑ LVEF ≤ 35% 
❑ Sinus rhythm or [[Left bundle branch block|LBBB]] 
❑ [[Chronic heart failure resident survival guide#New York Heart Association (NYHA)|NYHA]] III - IV </div>|P02=LVEF ≤ 35%?}}
{{familytree | |,|-|^|-|.| | | |,|-|^|-|.| | |}}
{{familytree | Q01 | | Q02 | | Q03 | | Q04 | | |Q01='''Yes'''|Q02='''No'''|Q03='''Yes'''|Q04='''No'''}}
{{familytree | |!| | | |!| | | |!| | | |!| |}}
{{familytree | R01 | | |!| | | R02 | | R03 | |R01=[[Cardiac resynchronization therapy]] (CRT) ± [[Implantable cardioverter defibrillator]] (ICD)|R02=<div style="float: left; text-align: left; width: 15em; padding:1em;">[[Implantable cardioverter defibrillator]] 
❑ As primary prevention of [[sudden cardiac death]] in:
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT </div>|R03=Continue GDMT}}
{{familytree | |`|-|v|-|'| | |}}
{{familytree | | | S01 | | |S01=Persistent symptoms (Advanced heart failure)}}
{{familytree | | | |!| | |}}
{{familytree | | | T01 | |T01=IV inotropes or vasodilators }}
{{familytree | | | |!| | |}}
{{familytree | | | U01 | | U01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''[[Mechanical circulatory support]] (MCS)<ref name="pmid21300961">{{cite journal| author=Naidu SS| title=Novel percutaneous cardiac assist devices: the science of and indications for hemodynamic support. | journal=Circulation | year= 2011 | volume= 123 | issue= 5 | pages= 533-43 | pmid=21300961 | doi=10.1161/CIRCULATIONAHA.110.945055 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21300961 }} </ref>:''' 
* [[Intra-aortic balloon pump]] 
* [[Ventricular assist device|LVAD]] - as bridge to recovery,<ref name="pmid17079761">{{cite journal| author=Birks EJ, Tansley PD, Hardy J, George RS, Bowles CT, Burke M et al.| title=Left ventricular assist device and drug therapy for the reversal of heart failure. | journal=N Engl J Med | year= 2006 | volume= 355 | issue= 18 | pages= 1873-84 | pmid=17079761 | doi=10.1056/NEJMoa053063 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17079761 }} </ref> transplant, or as definitive therapy<ref name="pmid19920051">{{cite journal| author=Slaughter MS, Rogers JG, Milano CA, Russell SD, Conte JV, Feldman D et al.| title=Advanced heart failure treated with continuous-flow left ventricular assist device. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 23 | pages= 2241-51 | pmid=19920051 | doi=10.1056/NEJMoa0909938 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19920051 }} </ref> 
❑ General indications:
:❑ LVEF ≤ 25% 
:❑ NYHA III or IV on chronic GDMT 
:❑ Predicted 1-2 year mortality</div>|R03=Continue GDMT</div>}}
{{familytree | | | |!| |}}
{{familytree | | | V01 | V01=[[Heart transplantation|Cardiac transplantation]]}}
{{familytree/end}}

==Hypertension==
{{familytree/start}}
{{familytree | |,|-|-|-|v|-|-|^|-|-|v|-|-|-|.| | |}}
{{familytree | J01 | | J02 | | | | J03 |~| J04 | | |J01=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Dry''' 
----
❑ Consider outpatient treatment ❑ Dietary sodium restriction (2-3 g daily) ❑ [[Smoking cessation]] ❑ [[Alcohol]] abstinence (≤2 standard drinks per day for men; ≤1 for women) ❑ Encourage exercise/physical activity 
'''Although [[ACE inhibitors]] and [[beta blockers]] should not be administered to patients with [[acute decompensated heart failure]], if the patient is compensated in the outpatient setting then administer: ❑ [[ACE inhibitors]] or ([[ARBs]]) if LVEF is ≤ 40% ❑ [[Beta blockers]]'''<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> </div>|

J02=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Wet''' 
----
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] 
❑ Treat co-morbidities [[HTN]], [[DM]], [[CAD]], [[AF]]</div>|

J03=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Wet''' 
----
❑ CCU admission 
❑ Invasive hemodynamic monitoring (arterial line, consider pulmonary catheter if volume status unclear) 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) ❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] while monitoring [[blood pressure]] ❑ IV vasodilators</div>|J04=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Dry''' 
----
❑ CCU admission 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) 
❑ '''Persistent organ hypoperfusion''' (e.g., low urine output or persistent low SBP<85) 
:❑ [[Norepinephrine]] 0.2–1.0 mcg/kg/min, titrate to maintain a blood pressure of </div>}}
{{familytree | | | | | |!| | | | | |!| | | |!| | | | |}}
{{familytree | | | | | |`|-|-|v|-|-|^|-|-|-|'| | |}}
{{familytree | | | | | | | | X01 | | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | K01 | | | |K01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | | | | | |}}
{{familytree | | | | | | | | L01 | | | |L01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

==Underlying Anatomic Abnormalities Causing Heart Failure==
Heart failure may result from an abnormality of any one of the anatomical structures of the heart:
*Disorders of the [[great vessels]] (e.g. [[pulmonary hypertension]])
*[[Endocardium]]
*[[Myocardium]]
*[[Pericardium]]
*[[Valvular heart disease]] or

==Systolic versus Diastolic Heart Failure==
Patients may be broadly classified as having heart failure with depressed contractility or depressed relaxation
===Systolic Dysfunction===
The [[left ventricular ejection fraction]] is reduced in [[systolic dysfunction]] and there is depressed contractility of the heart.
===Disastolic Dysfunciton===
The [[left ventricular ejection fraction]] is preserved in [[diastolic dysfunction]] and there is an abnormality in myocardial relaxation or excessive myocardial stiffness. Systolic and diastolic dysfunction commonly occur in conjunction with each other.

==Left, Right and Biventricular Failure==
Another common method of classifying heart failure is based upon the ventricle involved (left sided versus right sided).
===Left Heart Failure===
*There is impaired left ventricular function with reduced flow into the aorta.
===Right Heart Failure===
*There is impaired right ventricular function with reduced flow into the pulmonary artery and lungs.
===Biventricular Failure===
*The most common cause of right heart failure is left heart failure, and mixed presentations are common, especially when the cardiac septum is involved.

==High Output Versus Low Output Failure==
===Low Output Failure===
*The [[cardiac output]] is reduced, and the [[systemic vascular resistance]] ([[SVR]]) is high. In low output failure, there is an inadequate supply of blood flow to meet normal metabolic demands.

===High Output Failure===
*The [[cardiac output]] is increased, and the [[systemic vascular resistance]] ([[SVR]]) is low. Rather than an inadequate supply of blood flow to meet normal metabolic demands as occurs in low output failure, in high output failure there is an excess requirement for oxygen and nutrients and the demand outstrips what the heart can provide.<ref>{{DorlandsDict|nine/000953450|high-output heart failure}}</ref> Causes of high output heart failure include severe [[anemia]], Gram negative [[septicaemia]], [[beriberi]] (vitamin B1/thiamine deficiency), [[thyrotoxicosis]], [[Paget's disease of bone|Paget's disease]], [[arteriovenous fistula]]e, or [[arteriovenous malformation]]s.

==Causes of Acute or Decompensated Heart Failure==
Chronic stable heart failure may easily decompensate. This most commonly results from an intercurrent illness (such as [[pneumonia]]), [[myocardial infarction]] (a heart attack), [[cardiac arrhythmia|arrhythmias]], uncontrolled [[hypertension]], or a patient's failure to maintain a fluid restriction, diet, or medication.<ref name="OPTIMIZE-HF">{{cite journal |author=Fonarow GC, Abraham WT, Albert NM, ''et al.'' |title=Factors Identified as Precipitating Hospital Admissions for Heart Failure and Clinical Outcomes: Findings From OPTIMIZE-HF |journal=Arch. Intern. Med. |volume=168 |issue=8 |pages=847–854 |year=2008 |month=April |pmid=18443260 |doi=10.1001/archinte.168.8.847}}</ref> Other well recognized precipitating factors include [[anemia]] and [[hyperthyroidism]] which place additional strain on the heart muscle. Excessive fluid or salt intake, and medication that causes fluid retention such as [[Non-steroidal anti-inflammatory drug|NSAIDs]] and [[thiazolidinedione]]s, may also precipitate decompensation.<ref>{{cite journal |author=Nieminen MS, Böhm M, Cowie MR, ''et al.'' |title=Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the Task Force on Acute Heart Failure of the European Society of Cardiology |journal=Eur. Heart J. |volume=26 |issue=4 |pages=384–416 |year=2005 |month=February |pmid=15681577 |doi=10.1093/eurheartj/ehi044 |url=http://eurheartj.oxfordjournals.org/cgi/content/full/26/4/384}}</ref>

==Differential Diagnosis of the Underlying Causes of Chronic Heart Failure==
===Common Causes of Left Sided Heart Failure===
* [[Aortic Regurgitation|Aortic regurgitation]]
* [[Aortic Stenosis|Aortic stenosis]]
* [[Hypertension]]
* [[Mitral Regurgitation|Mitral regurgitation]]
* [[Myocardial ischemia]]

A 19 year study of 13,000 healthy adults in the United States (the [[National Health and Nutrition Examination Survey]] (NHANES I) found the following causes ranked by Population Attributable Risk score:<ref>{{cite journal |author=He J; Ogden LG; Bazzano LA; Vupputuri S, ''et al.'' |title=Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study|journal=Arch. Intern. Med. |volume=161 |issue=7 |pages=996–1002|year=2001 |pmid= 11295963 |doi=10.1001/archinte.161.7.996 }}</ref>
#[[Ischaemic heart disease]] 62%
#[[Tobacco smoking|Cigarette smoking]] 16%
#[[Hypertension]] (high blood pressure)10%
#[[Obesity]] 8%
#[[Diabetes]] 3%
#[[Valvular heart disease]] 2% (much higher in older populations)

===Cardiomyopathies and Inflammatory Diseases===

=====[[Restrictive Cardiomyopathies]]=====
*[[Alcohol-Induced cardiomyopathy]]
*[[Amyloidosis]]
*[[Anthracycline induced cardiomyopathy]]
*[[Anthracyclines]]
*[[Arrhythmogenic right ventricular dysplasia]]
*[[Becker's muscular dystrophy]]
*[[Cardiac transplant]]
*[[Cocaine related cardiomyopathy]]
*[[Diabetic cardiomyopathy]]
*[[Endocardial fibrosis]]
*[[Eosinophilic heart disease]]
*[[Hemochromatosis]]
*Primary (idiopathic)
*[[Kearns-Sayre syndrome]]
*[[Radiation therapy]]
*[[Sarcoidosis]]
*Storage diseases
*[[Tumor]] infiltration

=====[[Dilated Cardiomyopathies]]=====
*[[Duchenne muscular dystrophy]]
*[[Chagas' disease]]
*[[Limb-girdle muscular dystrophy]]
*[[Mitochondrial myopathy]]
*[[Peripartum cardiomyopathy]]
*[[Trastuzumab]] [[Herceptin-lnduced Cardiomyopathy]]

=====Inflammatory Cardiomyopathies=====

*[[Bacterial Myocarditis]]
*[[Fungal myocarditis]]
*[[Giant Cell Myocarditis]]
*[[Myocarditis|Protozoal Myocarditis]]: [[Trypanosomiasis]] ([[Chagas Disease]])
*[[Rickettsial Myocarditis]]
*[[Sarcoidosis]]
*[[Spirochetal Infections]]
*[[Viral Myocarditis]]

===Congestive Heart Failure as a Consequence of Valvular Heart Disease===
*[[Acute aortic regurgitation]]
*[[Acute mitral regurgitation]]
*[[Aortic stenosis with Left Ventricular Systolic Dysfunction]]
*[[Chronic aortic regurgitation]]
*[[Chronic mitral regurgitation]]
*[[Mitral Stenosis]]

===Congestive Hert Failure Secondary to Congenital Heart Disease===

'''A. Causes of Congestive Heart Failure in Adults with Unoperated Congenital Heart Diseases'''
*[[Arrhythmia]]
*[[Atrial septal defect]] with [[mitral regurgitation]]] secondary to myxomatous mitral valve
*[[Congenital mitral regurgitation]]
*[[Drug abuse]], [[alcohol abuse]]
*[[Eisenmenger's syndrome]]
*[[Endocarditis]]
*Fibrocalcific degeneration of abnormal [[aortic valve]]
*[[Pregnancy]]
*Systemic ventricular dysfunction and/or [[tricuspid regurgitation]] in congenitally corrected transposition of the great arteries
*Other degenerative diseases ([[coronary artery disease]], [[hypertension]])
'''B. Causes of Congestive Heart Failure in Adults with Operated Congenital Heart Diseases'''
*[[Arrhythmia]]
*[[Endocarditis]]
*Myocardial dysfunction
*Persistent left-to-right shunt
*Prosthetic valve dysfunction
*Pulmonary vascular disease
*Status post [[Fontan operation]]
*Valvular regurgitation
*Other degenerative diseases ([[coronary artery disease]], [[hypertension]])

=== Right Ventricular Failure ===
Factors affected right ventricle and to be eliminated during management of congestive heart failure.
A. Right ventricular myocardial dysfunction
#[[Right ventricular myocardial infarction]]
#[[Dilated cardiomyopathy]]
#[[Arrhythmogenic right ventricular dysplasia|Right ventricular dysplasia]]
B. Primary right ventricular pressure overload
#[[Left ventricular failure]]
#[[Mitral valve]] disease
#[[Atrial myxoma]]
#[[Pulmonary veno-occlusive disease]]
#[[Cor pulmonale]]
#:*[[Chronic obstructive pulmonary disease]]
#:*[[Primary pulmonary hypertension]]
#:*[[Pulmonary embolism]]
#[[Pulmonic stenosis]]
#:*[[Supravalvular pulmonic stenosis]]
#:*[[Valvular pulmonic stenosis]]
#:*[[Subvalvular pulmonic stenosis]]
#[[Ventricular septal defect]]
#Aortopulmonary communication
C. Primary right ventricular volume overload
#[[Pulmonic regurgitation]]
#[[Tricuspid regurgitation]]
#[[Atrial septal defect]]
#[[Partial anomalous pulmonary venous return]]
D. Impediment to right ventricular inflow
#[[Tricuspid stenosis]]
#[[Cardiac tamponade]]
#[[pericarditis |Constrictive pericarditis]]
#[[cardiomyopathy|Restrictive cardiomyopathy]]

== Differential Diagnosis of Causes of Heart Failure Segregated by Left and Right Sided Heart Failure==
===Left Ventricular Failure===
====Most Common Causes:====
* [[Aortic Regurgitation|Aortic regurgitation]]
* [[Aortic Stenosis|Aortic stenosis]]
* [[Hypertension]]
* [[Mitral Regurgitation|Mitral regurgitation]]
* [[Myocardial ischemia]]

====Expanded List of Causes:====
* [[Atrial fibrillation]]
* [[Alcoholism]]
* [[Anemia]]
* [[Angina]]
* [[Aortic Regurgitation|Aortic regurgitation]]
* [[Aortic Stenosis]]
* [[Arteriovenous fistula]]
* [[Beriberi]]
* [[aneurysm|Cardiac aneurysm]]
* [[Cardiomyopathy]]
* [[pericarditis|Constrictive pericarditis]]
* [[Drugs]], [[toxin]]s
* [[Hypertension]]
* [[Hyperthyroidism]]
* [[Hypovolemia]]
* [[Hypoxia]]
* Mediastinal tumors
* [[Mitral Regurgitation]]
* [[Myocardial Infarction]]
* [[Paget's Disease]]
* [[Pancoast's Tumor]]
* [[Pericardial effusion]]
* [[Pericardial tamponade]]
* [[Perimyocarditis]]
* [[Protein deficiency]]
* [[Restrictive cardiomyopathy]]
* [[Papillary muscle rupture|Rupture of the papillary muscles]]
* [[Sepsis]]
* [[Superior Vena Cava]] thrombosis

===Right Ventricular Failure ===
====Most Common Causes:====
* [[Cardiomyopathy]]
* [[Cor pulmonale]]
* [[myocarditis|Diffuse myocarditis]]
* Left heart failure

====Other Causes:====
* After [[left ventricular failure]]
* After pulmonary resection
* [[Alveolitis|Allergic alveolitis]]
* [[asthma|Bronchial asthma]]
* [[bronchitis|Chronic bronchitis]]
* [[Alveolitis|Honeycomb lung]]
* [[Hyperglobulia]]
* [[Emphysema]]
* [[Mitral Stenosis]]
* [[Right ventricular myocardial infarction]]
* [[Pickwickian Syndrome]]
* Pleural fibrosis
* [[Pneumoconiosis]]
* [[Pulmonary fibrosis]]
* [[Pulmonic regurgitation]]
* [[Pulmonic stenosis]]
* [[Sarcoidosis]]
* [[pulmonary emboli|Severe relapsing pulmonary emboli]]
* [[Silicosis]]
* [[Tachycardia]]
* [[Tricuspid insufficiency]]

===Others===
* [[Ascorbic acid deficiency]]
* [[Cardiac amyloidosis]]
* [[Carnitine deficiency]]
* Cervical vein stasis of non-cardiac genesis
* [[Congenital heart disease]]
* [[Cyanosis]] of non-cardiac genesis
* [[Diabetes Mellitus]]
* [[Ddx:Dyspnea|Dyspnea]] of non-cardiac genesis
* [[Edema]] of non-cardiac genesis
* [[Hemochromatosis]]
* [[Pleural effusion]] of non-cardiac genesis
* [[Pulmonary edema]] of non-cardiac genesis
* [[Thiamine deficiency]]
* [[Thyroid disease]]

Sandbox/22

2014-05-09T16:00:27Z

Ayokunle Olubaniyi:

==CHF==

{{familytree | | | |!| | | |!| | |}}
{{familytree | | | E01 |~| E02 | |E01=[[Chronic heart failure resident survival guide#Diuretic Therapy|Diuretic therapy]]|E02= [[ACE inhibitors]] '''AND''' [[Beta blockers]]}}
{{familytree | | | | | | | |!| |}}
{{familytree | | | | | | | F01 | |F01=Intolerant to ACE-I}}
{{familytree | | | | | |,|-|^|-|.| |}}
{{familytree | | | | | G01 | | G02 | |G01=[[Cough]]|G02=[[Renal insufficiency]] or [[angioedema]]}}
{{familytree | | | | | |!| | | |!| |}}
{{familytree | | | | | H01 | | H02 | |H01=[[Angiotensin II receptor antagonist|ARBs]]|H02=[[Hydralazine]]/[[isosorbide dinitrate]]<ref name="pmid3520315">{{cite journal| author=Cohn JN, Archibald DG, Ziesche S, Franciosa JA, Harston WE, Tristani FE et al.| title=Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative Study. | journal=N Engl J Med | year= 1986 | volume= 314 | issue= 24 | pages= 1547-52 | pmid=3520315 | doi=10.1056/NEJM198606123142404 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3520315 }} </ref>}}
{{familytree | | | | | |`|-|v|-|'| |}}
{{familytree | | | | | | | I01 | | | I01=Persistent symptoms?}}
{{familytree | | | | | |,|-|^|-|.| |}}
{{familytree | | | | | J01 | | J02 | J01='''Yes'''|J02='''No'''}}
{{familytree | | | | | |!| | | |!| | }}
{{familytree | | | | | K01 | | |!| | K01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Add:''' 
❑ [[Aldosterone]] or [[eplerenone]] if: 
:❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
:❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
:❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
:❑ NYHA class II–IV HF with LVEF ≤ 35% '''OR''' 
❑ [[Hydralazine]]/[[isosorbide dinitrate]] 
:❑ African Americans with NYHA class III–IV HFrEF on GDMT '''OR''' 
❑ [[ARBs]]<ref name="pmid13678868">{{cite journal| author=Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, Michelson EL et al.| title=Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme. | journal=Lancet | year= 2003 | volume= 362 | issue= 9386 | pages= 759-66 | pmid=13678868 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13678868 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15122853 Review in: ACP J Club. 2004 Mar-Apr;140(2):32-3] </ref>

</div>}}
{{familytree | | | | | |!| | | |!| | |}}
{{familytree | | | | | L01 | | |!| | |L01=Persistent symptoms?}}
{{familytree | | | | | |!| | | |!| |}}
{{familytree | | | | | M01 | | |!| |M01=Add [[digoxin]] }}
{{familytree | | | | | |!| | | |!| | |}}
{{familytree | | | | | N01 | | |!| | |N01=Persistent symptoms?}}
{{familytree | | | |,|-|^|-|.| |!| | }}
{{familytree | | | O01 | | O02 |!| | |O01='''Yes'''|O02='''No'''}}
{{familytree | | | |!| | | |`|-|^|-|.| | |}}
{{familytree | | | P01 | | | | | | P02 | | | | P01=<div style="float: left; text-align: left; width: 15em; padding:1em;">
❑ LVEF ≤ 35% 
❑ Sinus rhythm or [[Left bundle branch block|LBBB]] 
❑ [[Chronic heart failure resident survival guide#New York Heart Association (NYHA)|NYHA]] III - IV </div>|P02=LVEF ≤ 35%?}}
{{familytree | |,|-|^|-|.| | | |,|-|^|-|.| | |}}
{{familytree | Q01 | | Q02 | | Q03 | | Q04 | | |Q01='''Yes'''|Q02='''No'''|Q03='''Yes'''|Q04='''No'''}}
{{familytree | |!| | | |!| | | |!| | | |!| |}}
{{familytree | R01 | | |!| | | R02 | | R03 | |R01=[[Cardiac resynchronization therapy]] (CRT) ± [[Implantable cardioverter defibrillator]] (ICD)|R02=<div style="float: left; text-align: left; width: 15em; padding:1em;">[[Implantable cardioverter defibrillator]] 
❑ As primary prevention of [[sudden cardiac death]] in:
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT </div>|R03=Continue GDMT}}
{{familytree | |`|-|v|-|'| | |}}
{{familytree | | | S01 | | |S01=Persistent symptoms (Advanced heart failure)}}
{{familytree | | | |!| | |}}
{{familytree | | | T01 | |T01=IV inotropes or vasodilators }}
{{familytree | | | |!| | |}}
{{familytree | | | U01 | | U01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''[[Mechanical circulatory support]] (MCS)<ref name="pmid21300961">{{cite journal| author=Naidu SS| title=Novel percutaneous cardiac assist devices: the science of and indications for hemodynamic support. | journal=Circulation | year= 2011 | volume= 123 | issue= 5 | pages= 533-43 | pmid=21300961 | doi=10.1161/CIRCULATIONAHA.110.945055 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21300961 }} </ref>:''' 
* [[Intra-aortic balloon pump]] 
* [[Ventricular assist device|LVAD]] - as bridge to recovery,<ref name="pmid17079761">{{cite journal| author=Birks EJ, Tansley PD, Hardy J, George RS, Bowles CT, Burke M et al.| title=Left ventricular assist device and drug therapy for the reversal of heart failure. | journal=N Engl J Med | year= 2006 | volume= 355 | issue= 18 | pages= 1873-84 | pmid=17079761 | doi=10.1056/NEJMoa053063 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17079761 }} </ref> transplant, or as definitive therapy<ref name="pmid19920051">{{cite journal| author=Slaughter MS, Rogers JG, Milano CA, Russell SD, Conte JV, Feldman D et al.| title=Advanced heart failure treated with continuous-flow left ventricular assist device. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 23 | pages= 2241-51 | pmid=19920051 | doi=10.1056/NEJMoa0909938 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19920051 }} </ref> 
❑ General indications:
:❑ LVEF ≤ 25% 
:❑ NYHA III or IV on chronic GDMT 
:❑ Predicted 1-2 year mortality</div>|R03=Continue GDMT</div>}}
{{familytree | | | |!| |}}
{{familytree | | | V01 | V01=[[Heart transplantation|Cardiac transplantation]]}}

==Hypertension==
{{familytree/start}}
{{familytree | |,|-|-|-|v|-|-|^|-|-|v|-|-|-|.| | |}}
{{familytree | J01 | | J02 | | | | J03 |~| J04 | | |J01=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Dry''' 
----
❑ Consider outpatient treatment ❑ Dietary sodium restriction (2-3 g daily) ❑ [[Smoking cessation]] ❑ [[Alcohol]] abstinence (≤2 standard drinks per day for men; ≤1 for women) ❑ Encourage exercise/physical activity 
'''Although [[ACE inhibitors]] and [[beta blockers]] should not be administered to patients with [[acute decompensated heart failure]], if the patient is compensated in the outpatient setting then administer: ❑ [[ACE inhibitors]] or ([[ARBs]]) if LVEF is ≤ 40% ❑ [[Beta blockers]]'''<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> </div>|

J02=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Wet''' 
----
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] 
❑ Treat co-morbidities [[HTN]], [[DM]], [[CAD]], [[AF]]</div>|

J03=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Wet''' 
----
❑ CCU admission 
❑ Invasive hemodynamic monitoring (arterial line, consider pulmonary catheter if volume status unclear) 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) ❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] while monitoring [[blood pressure]] ❑ IV vasodilators</div>|J04=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Dry''' 
----
❑ CCU admission 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) 
❑ '''Persistent organ hypoperfusion''' (e.g., low urine output or persistent low SBP<85) 
:❑ [[Norepinephrine]] 0.2–1.0 mcg/kg/min, titrate to maintain a blood pressure of </div>}}
{{familytree | | | | | |!| | | | | |!| | | |!| | | | |}}
{{familytree | | | | | |`|-|-|v|-|-|^|-|-|-|'| | |}}
{{familytree | | | | | | | | X01 | | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | K01 | | | |K01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | | | | | |}}
{{familytree | | | | | | | | L01 | | | |L01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

==Underlying Anatomic Abnormalities Causing Heart Failure==
Heart failure may result from an abnormality of any one of the anatomical structures of the heart:
*Disorders of the [[great vessels]] (e.g. [[pulmonary hypertension]])
*[[Endocardium]]
*[[Myocardium]]
*[[Pericardium]]
*[[Valvular heart disease]] or

==Systolic versus Diastolic Heart Failure==
Patients may be broadly classified as having heart failure with depressed contractility or depressed relaxation
===Systolic Dysfunction===
The [[left ventricular ejection fraction]] is reduced in [[systolic dysfunction]] and there is depressed contractility of the heart.
===Disastolic Dysfunciton===
The [[left ventricular ejection fraction]] is preserved in [[diastolic dysfunction]] and there is an abnormality in myocardial relaxation or excessive myocardial stiffness. Systolic and diastolic dysfunction commonly occur in conjunction with each other.

==Left, Right and Biventricular Failure==
Another common method of classifying heart failure is based upon the ventricle involved (left sided versus right sided).
===Left Heart Failure===
*There is impaired left ventricular function with reduced flow into the aorta.
===Right Heart Failure===
*There is impaired right ventricular function with reduced flow into the pulmonary artery and lungs.
===Biventricular Failure===
*The most common cause of right heart failure is left heart failure, and mixed presentations are common, especially when the cardiac septum is involved.

==High Output Versus Low Output Failure==
===Low Output Failure===
*The [[cardiac output]] is reduced, and the [[systemic vascular resistance]] ([[SVR]]) is high. In low output failure, there is an inadequate supply of blood flow to meet normal metabolic demands.

===High Output Failure===
*The [[cardiac output]] is increased, and the [[systemic vascular resistance]] ([[SVR]]) is low. Rather than an inadequate supply of blood flow to meet normal metabolic demands as occurs in low output failure, in high output failure there is an excess requirement for oxygen and nutrients and the demand outstrips what the heart can provide.<ref>{{DorlandsDict|nine/000953450|high-output heart failure}}</ref> Causes of high output heart failure include severe [[anemia]], Gram negative [[septicaemia]], [[beriberi]] (vitamin B1/thiamine deficiency), [[thyrotoxicosis]], [[Paget's disease of bone|Paget's disease]], [[arteriovenous fistula]]e, or [[arteriovenous malformation]]s.

==Causes of Acute or Decompensated Heart Failure==
Chronic stable heart failure may easily decompensate. This most commonly results from an intercurrent illness (such as [[pneumonia]]), [[myocardial infarction]] (a heart attack), [[cardiac arrhythmia|arrhythmias]], uncontrolled [[hypertension]], or a patient's failure to maintain a fluid restriction, diet, or medication.<ref name="OPTIMIZE-HF">{{cite journal |author=Fonarow GC, Abraham WT, Albert NM, ''et al.'' |title=Factors Identified as Precipitating Hospital Admissions for Heart Failure and Clinical Outcomes: Findings From OPTIMIZE-HF |journal=Arch. Intern. Med. |volume=168 |issue=8 |pages=847–854 |year=2008 |month=April |pmid=18443260 |doi=10.1001/archinte.168.8.847}}</ref> Other well recognized precipitating factors include [[anemia]] and [[hyperthyroidism]] which place additional strain on the heart muscle. Excessive fluid or salt intake, and medication that causes fluid retention such as [[Non-steroidal anti-inflammatory drug|NSAIDs]] and [[thiazolidinedione]]s, may also precipitate decompensation.<ref>{{cite journal |author=Nieminen MS, Böhm M, Cowie MR, ''et al.'' |title=Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the Task Force on Acute Heart Failure of the European Society of Cardiology |journal=Eur. Heart J. |volume=26 |issue=4 |pages=384–416 |year=2005 |month=February |pmid=15681577 |doi=10.1093/eurheartj/ehi044 |url=http://eurheartj.oxfordjournals.org/cgi/content/full/26/4/384}}</ref>

==Differential Diagnosis of the Underlying Causes of Chronic Heart Failure==
===Common Causes of Left Sided Heart Failure===
* [[Aortic Regurgitation|Aortic regurgitation]]
* [[Aortic Stenosis|Aortic stenosis]]
* [[Hypertension]]
* [[Mitral Regurgitation|Mitral regurgitation]]
* [[Myocardial ischemia]]

A 19 year study of 13,000 healthy adults in the United States (the [[National Health and Nutrition Examination Survey]] (NHANES I) found the following causes ranked by Population Attributable Risk score:<ref>{{cite journal |author=He J; Ogden LG; Bazzano LA; Vupputuri S, ''et al.'' |title=Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study|journal=Arch. Intern. Med. |volume=161 |issue=7 |pages=996–1002|year=2001 |pmid= 11295963 |doi=10.1001/archinte.161.7.996 }}</ref>
#[[Ischaemic heart disease]] 62%
#[[Tobacco smoking|Cigarette smoking]] 16%
#[[Hypertension]] (high blood pressure)10%
#[[Obesity]] 8%
#[[Diabetes]] 3%
#[[Valvular heart disease]] 2% (much higher in older populations)

===Cardiomyopathies and Inflammatory Diseases===

=====[[Restrictive Cardiomyopathies]]=====
*[[Alcohol-Induced cardiomyopathy]]
*[[Amyloidosis]]
*[[Anthracycline induced cardiomyopathy]]
*[[Anthracyclines]]
*[[Arrhythmogenic right ventricular dysplasia]]
*[[Becker's muscular dystrophy]]
*[[Cardiac transplant]]
*[[Cocaine related cardiomyopathy]]
*[[Diabetic cardiomyopathy]]
*[[Endocardial fibrosis]]
*[[Eosinophilic heart disease]]
*[[Hemochromatosis]]
*Primary (idiopathic)
*[[Kearns-Sayre syndrome]]
*[[Radiation therapy]]
*[[Sarcoidosis]]
*Storage diseases
*[[Tumor]] infiltration

=====[[Dilated Cardiomyopathies]]=====
*[[Duchenne muscular dystrophy]]
*[[Chagas' disease]]
*[[Limb-girdle muscular dystrophy]]
*[[Mitochondrial myopathy]]
*[[Peripartum cardiomyopathy]]
*[[Trastuzumab]] [[Herceptin-lnduced Cardiomyopathy]]

=====Inflammatory Cardiomyopathies=====

*[[Bacterial Myocarditis]]
*[[Fungal myocarditis]]
*[[Giant Cell Myocarditis]]
*[[Myocarditis|Protozoal Myocarditis]]: [[Trypanosomiasis]] ([[Chagas Disease]])
*[[Rickettsial Myocarditis]]
*[[Sarcoidosis]]
*[[Spirochetal Infections]]
*[[Viral Myocarditis]]

===Congestive Heart Failure as a Consequence of Valvular Heart Disease===
*[[Acute aortic regurgitation]]
*[[Acute mitral regurgitation]]
*[[Aortic stenosis with Left Ventricular Systolic Dysfunction]]
*[[Chronic aortic regurgitation]]
*[[Chronic mitral regurgitation]]
*[[Mitral Stenosis]]

===Congestive Hert Failure Secondary to Congenital Heart Disease===

'''A. Causes of Congestive Heart Failure in Adults with Unoperated Congenital Heart Diseases'''
*[[Arrhythmia]]
*[[Atrial septal defect]] with [[mitral regurgitation]]] secondary to myxomatous mitral valve
*[[Congenital mitral regurgitation]]
*[[Drug abuse]], [[alcohol abuse]]
*[[Eisenmenger's syndrome]]
*[[Endocarditis]]
*Fibrocalcific degeneration of abnormal [[aortic valve]]
*[[Pregnancy]]
*Systemic ventricular dysfunction and/or [[tricuspid regurgitation]] in congenitally corrected transposition of the great arteries
*Other degenerative diseases ([[coronary artery disease]], [[hypertension]])
'''B. Causes of Congestive Heart Failure in Adults with Operated Congenital Heart Diseases'''
*[[Arrhythmia]]
*[[Endocarditis]]
*Myocardial dysfunction
*Persistent left-to-right shunt
*Prosthetic valve dysfunction
*Pulmonary vascular disease
*Status post [[Fontan operation]]
*Valvular regurgitation
*Other degenerative diseases ([[coronary artery disease]], [[hypertension]])

=== Right Ventricular Failure ===
Factors affected right ventricle and to be eliminated during management of congestive heart failure.
A. Right ventricular myocardial dysfunction
#[[Right ventricular myocardial infarction]]
#[[Dilated cardiomyopathy]]
#[[Arrhythmogenic right ventricular dysplasia|Right ventricular dysplasia]]
B. Primary right ventricular pressure overload
#[[Left ventricular failure]]
#[[Mitral valve]] disease
#[[Atrial myxoma]]
#[[Pulmonary veno-occlusive disease]]
#[[Cor pulmonale]]
#:*[[Chronic obstructive pulmonary disease]]
#:*[[Primary pulmonary hypertension]]
#:*[[Pulmonary embolism]]
#[[Pulmonic stenosis]]
#:*[[Supravalvular pulmonic stenosis]]
#:*[[Valvular pulmonic stenosis]]
#:*[[Subvalvular pulmonic stenosis]]
#[[Ventricular septal defect]]
#Aortopulmonary communication
C. Primary right ventricular volume overload
#[[Pulmonic regurgitation]]
#[[Tricuspid regurgitation]]
#[[Atrial septal defect]]
#[[Partial anomalous pulmonary venous return]]
D. Impediment to right ventricular inflow
#[[Tricuspid stenosis]]
#[[Cardiac tamponade]]
#[[pericarditis |Constrictive pericarditis]]
#[[cardiomyopathy|Restrictive cardiomyopathy]]

== Differential Diagnosis of Causes of Heart Failure Segregated by Left and Right Sided Heart Failure==
===Left Ventricular Failure===
====Most Common Causes:====
* [[Aortic Regurgitation|Aortic regurgitation]]
* [[Aortic Stenosis|Aortic stenosis]]
* [[Hypertension]]
* [[Mitral Regurgitation|Mitral regurgitation]]
* [[Myocardial ischemia]]

====Expanded List of Causes:====
* [[Atrial fibrillation]]
* [[Alcoholism]]
* [[Anemia]]
* [[Angina]]
* [[Aortic Regurgitation|Aortic regurgitation]]
* [[Aortic Stenosis]]
* [[Arteriovenous fistula]]
* [[Beriberi]]
* [[aneurysm|Cardiac aneurysm]]
* [[Cardiomyopathy]]
* [[pericarditis|Constrictive pericarditis]]
* [[Drugs]], [[toxin]]s
* [[Hypertension]]
* [[Hyperthyroidism]]
* [[Hypovolemia]]
* [[Hypoxia]]
* Mediastinal tumors
* [[Mitral Regurgitation]]
* [[Myocardial Infarction]]
* [[Paget's Disease]]
* [[Pancoast's Tumor]]
* [[Pericardial effusion]]
* [[Pericardial tamponade]]
* [[Perimyocarditis]]
* [[Protein deficiency]]
* [[Restrictive cardiomyopathy]]
* [[Papillary muscle rupture|Rupture of the papillary muscles]]
* [[Sepsis]]
* [[Superior Vena Cava]] thrombosis

===Right Ventricular Failure ===
====Most Common Causes:====
* [[Cardiomyopathy]]
* [[Cor pulmonale]]
* [[myocarditis|Diffuse myocarditis]]
* Left heart failure

====Other Causes:====
* After [[left ventricular failure]]
* After pulmonary resection
* [[Alveolitis|Allergic alveolitis]]
* [[asthma|Bronchial asthma]]
* [[bronchitis|Chronic bronchitis]]
* [[Alveolitis|Honeycomb lung]]
* [[Hyperglobulia]]
* [[Emphysema]]
* [[Mitral Stenosis]]
* [[Right ventricular myocardial infarction]]
* [[Pickwickian Syndrome]]
* Pleural fibrosis
* [[Pneumoconiosis]]
* [[Pulmonary fibrosis]]
* [[Pulmonic regurgitation]]
* [[Pulmonic stenosis]]
* [[Sarcoidosis]]
* [[pulmonary emboli|Severe relapsing pulmonary emboli]]
* [[Silicosis]]
* [[Tachycardia]]
* [[Tricuspid insufficiency]]

===Others===
* [[Ascorbic acid deficiency]]
* [[Cardiac amyloidosis]]
* [[Carnitine deficiency]]
* Cervical vein stasis of non-cardiac genesis
* [[Congenital heart disease]]
* [[Cyanosis]] of non-cardiac genesis
* [[Diabetes Mellitus]]
* [[Ddx:Dyspnea|Dyspnea]] of non-cardiac genesis
* [[Edema]] of non-cardiac genesis
* [[Hemochromatosis]]
* [[Pleural effusion]] of non-cardiac genesis
* [[Pulmonary edema]] of non-cardiac genesis
* [[Thiamine deficiency]]
* [[Thyroid disease]]

Chronic heart failure resident survival guide

2014-05-09T15:46:32Z

Ayokunle Olubaniyi: /* Overview */

<div style="width: 80%;">
__NOTOC__
{{CMG}}; {{AE}} {{AO}}
{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
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! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Chronic Heart Failure Resident Survival Guide Microchapters}}
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Diagnosis|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Treatment|Treatment]]
:[[Chronic heart failure resident survival guide#Diuretic Therapy|Diuretic Therapy]]
:[[Chronic heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
There are several goals in the chronic management of systolic [[heart failure]]. One goal of therapy is to improve the patient's symptoms, exercise tolerance and quality of life. [[Diuretics]], along with regular assessment of the patient's weight, minimizes fluid accumulation and the accompanying symptoms of [[dyspnea]] and [[orthopnea]]. Another goal is to reduce hospitalization and mortality. To achieve the second goal, patients with chronic [[heart failure]] should be administered an [[ACE inhibitor]] (or [[ARB]] if they are [[ACE]] intolerant) and a [[beta blocker]]. If the patient remains symptomatic, additional therapy may include an [[aldosterone antagonist]].

====Goals of Therapy====
{|class="wikitable"
! Goals!!Therapeutic intervention
|-
| To alleviate symptoms and signs||[[Diuretics]], [[morphine]] (no mortality benefit)
|-
| To reduce mortality||[[ACE inhibitors]]<ref name="pmid2883575">{{cite journal| author=| title=Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group. | journal=N Engl J Med | year= 1987 | volume= 316 | issue= 23 | pages= 1429-35 | pmid=2883575 | doi=10.1056/NEJM198706043162301 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2883575 }} </ref><ref name="pmid7654275">{{cite journal| author=Garg R, Yusuf S| title=Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. | journal=JAMA | year= 1995 | volume= 273 | issue= 18 | pages= 1450-6 | pmid=7654275 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7654275 }} </ref>, [[ARBs]], [[beta blockers]]<ref name="pmid11851582">{{cite journal| author=Foody JM, Farrell MH, Krumholz HM| title=beta-Blocker therapy in heart failure: scientific review. | journal=JAMA | year= 2002 | volume= 287 | issue= 7 | pages= 883-9 | pmid=11851582 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11851582 }} </ref>, [[aldosterone antagonists]]<ref name="pmid21073363">{{cite journal| author=Zannad F, McMurray JJ, Krum H, van Veldhuisen DJ, Swedberg K, Shi H et al.| title=Eplerenone in patients with systolic heart failure and mild symptoms. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 1 | pages= 11-21 | pmid=21073363 | doi=10.1056/NEJMoa1009492 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21073363 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21814643 Review in: J Fam Pract. 2011 Aug;60(8):482-4] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21558564 Review in: Evid Based Med. 2011 Aug;16(4):121-2] </ref>, [[hydralazine]] plus [[isosorbide dinitrate]]<ref name="pmid2057035">{{cite journal| author=Cohn JN, Johnson G, Ziesche S, Cobb F, Francis G, Tristani F et al.| title=A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. | journal=N Engl J Med | year= 1991 | volume= 325 | issue= 5 | pages= 303-10 | pmid=2057035 | doi=10.1056/NEJM199108013250502 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2057035 }} </ref>, [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref><ref name="pmid16087142">{{cite journal| author=Macchia A, Levantesi G, Franzosi MG, Geraci E, Maggioni AP, Marfisi R et al.| title=Left ventricular systolic dysfunction, total mortality, and sudden death in patients with myocardial infarction treated with n-3 polyunsaturated fatty acids. | journal=Eur J Heart Fail | year= 2005 | volume= 7 | issue= 5 | pages= 904-9 | pmid=16087142 | doi=10.1016/j.ejheart.2005.04.008 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16087142 }} </ref>, [[Cardiac resynchronization therapy|CRT]]<ref name="pmid15753115">{{cite journal| author=Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L et al.| title=The effect of cardiac resynchronization on morbidity and mortality in heart failure. | journal=N Engl J Med | year= 2005 | volume= 352 | issue= 15 | pages= 1539-49 | pmid=15753115 | doi=10.1056/NEJMoa050496 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15753115 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16134903 Review in: ACP J Club. 2005 Sep-Oct;143(2):29] </ref>, [[Implantable cardioverter defibrillator|ICD]]<ref name="pmid15659722">{{cite journal| author=Bardy GH, Lee KL, Mark DB, Poole JE, Packer DL, Boineau R et al.| title=Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. | journal=N Engl J Med | year= 2005 | volume= 352 | issue= 3 | pages= 225-37 | pmid=15659722 | doi=10.1056/NEJMoa043399 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15659722 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15989294 Review in: ACP J Club. 2005 Jul-Aug;143(1):6] </ref>
|-
| To reduce hospitalization||[[Digoxin]]<ref name="pmid9036306">{{cite journal| author=Digitalis Investigation Group| title=The effect of digoxin on mortality and morbidity in patients with heart failure. | journal=N Engl J Med | year= 1997 | volume= 336 | issue= 8 | pages= 525-33 | pmid=9036306 | doi=10.1056/NEJM199702203360801 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9036306 }} </ref>, [[ARBs]] (in [[Diastolic dysfunction|HFpEF]])<ref name="pmid13678871">{{cite journal| author=Yusuf S, Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ et al.| title=Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial. | journal=Lancet | year= 2003 | volume= 362 | issue= 9386 | pages= 777-81 | pmid=13678871 | doi=10.1016/S0140-6736(03)14285-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13678871 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15122853 Review in: ACP J Club. 2004 Mar-Apr;140(2):32-3] </ref>
|}

==Classification==
====Based on the Stage of Heart Failure====
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

====Based on the Severity of Congestive Heart Failure====
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Chronic heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.

===Common Causes===
* Cardiotoxic drugs (e.g. [[NSAIDs]], [[thiazolidinedione]], and certain [[chemotherapy]] drugs)
* [[Sepsis|Concurrent infections]] e.g., [[pneumonia]], viral illnesses
* Electrolyte imbalances
* Endocrine abnormalities - [[diabetes mellitus]], thyroid disorders ([[hyperthyroidism]], [[hypothyroidism]])
* Excessive [[alcohol]] or illicit drug use (e.g. [[cocaine]])
* Medication noncompliance
* [[Myocardial ischemia]] or [[infarction]]
* Noncompliance with dietary restrictions (e.g., sodium and fluid restriction)
* Progressive valvular disease (e.g. [[mitral regurgitation]])
* [[Pulmonary embolus]]
* [[Cardiac arrhythmias|Uncontrolled arrhythmias]]
* [[Hypertension|Uncontrolled hypertension]]

==Complete Diagnostic Approach==
The algorithm below describes the diagnostic approach to a patient with chronic heart failure.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' Acute respiratory distress syndrome;
'''BNP:''' B-type natriuretic peptide;
'''BUN:''' Blood urea nitrogen;
'''CAD:''' Coronary artery disease;
'''CBC:''' Complete blood count;
'''CCB:''' Calcium channel blocker;
'''CT:''' Computed tomography;
'''CXR:''' Chest x-ray;
'''DM:''' Diabetes mellitus;
'''EKG:''' Electrocardiogram;
'''HTN:''' Hypertension;
'''LVEF:''' Left ventricular ejection fraction;
'''LVH:''' Left ventricular hypertrophy;
'''MI:''' Myocardial infarction;
'''MRI:''' Magnetic resonance imaging;
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' Oral contraceptive pills;
'''PAWP:''' Pulmonary artery wedge pressure
'''TSH:''' Thyroid stimulating hormone
 

{{familytree/start}}
{{familytree | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
'''Symptoms of fluid accumulation:''' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
'''Symptoms of reduced cardiac output:''' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (may be suggestive of [[mesenteric ischemia]]) 
'''Symptoms suggestive of precipitating events:''' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitation]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
'''Nonspecific symptoms:''' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
'''Obtain a detailed history:''' 
❑ '''Past medical history:''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history:''' 
:❑ Noncompliance with medications 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s 
::❑ [[Thiazolidinedione]] 
❑ '''Family history:''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 
'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying infection) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] 
'''Assess weight:''' 
:❑ Subtract 'dry weight' from value to assess [[edema]] 
'''Skin:''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] 
'''Respiratory examination:''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 
'''Cardiovascular examination:''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (when right ventricular pressure is increased) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 
'''Abdominal examination:''' 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 
'''Extremity examination:''' 
❑ [[Pedal edema]] 
'''Neurological examination:''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | Q01 | |Q01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref> 
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] 
:❑ [[BUN]], [[creatinine]] 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 35 pg/mL 
:❑ NT-pro BNP ≤ 125 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ Cephalization
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior MI) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] (LBBB) 
:❑ [[Left atrial enlargement]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes 
❑ 2-D [[echocardiography]] with doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess LVEF and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] - in [[respiratory distress]] or [[shock]] 
'''Additional tests to rule out other etiologies:''' 
----
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
----
{{familytree | | | | | |!| | |}}
{{familytree | | | | | Y01 | |Y01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[COPD]]</td><td>❑ [[Dyspnea]], [[cough]], [[sputum]], history of smoking ❑ [[Spirometry]] reveals obstructive pattern</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ CXR - [[Pneumonia chest x ray|consolidation]]</td></tr>
<tr><td> [[Liver cirrhosis]]</td><td>❑ [[Jaundice]], [[fatigue]], [[peripheral edema]], [[coagulopathy]] ❑ Abnormal [[liver function tests]] ❑ [[Liver biopsy]] confirms the underlying cause</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors - trauma, immobilization, smoking, OCPs ❑ CT pulmonary angiography - clot in pulmonary artery</td></tr>
<tr><td>[[Peripartum cardiomyopathy]] </td><td>❑ [[Dyspnea]], [[orthopnea]], [[PND]] ❑ [[Pregnancy]] ❑ Absence of heart disease prior to onset of heart failure ❑ [[Echocardiography]] confirms [[left ventricular enlargement]] and [[systolic dysfunction]]</td></tr>
<tr><td>[[Nephrotic syndrome]] </td><td>❑ [[Dyspnea]], [[fatigue]], [[peripheral edema]] ❑ [[Urinalysis]] reveals [[proteinuria]] > 3.5g/24 hours</td></tr>
</table></div>}}
{{familytree/end}}

==Treatment==
{{familytree/start}}
{{familytree | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | C01 | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status''' 
❑ [[Congestion|Congestion at rest]] e.g., [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]] 
❑ Low perfusion at rest e.g., [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | Z01 | | | |Z01='''Does the patient have any evidence of fluid retention?'''}}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01='''Yes'''|D02='''No'''}}
{{familytree | | | |!| | | |!| | |}}
{{familytree | | | E01 |~| E02 | |E01=[[Chronic heart failure resident survival guide#Diuretic Therapy|Diuretic therapy]]|E02= [[ACE inhibitors]] '''AND''' [[Beta blockers]]}}
{{familytree | | | | | | | |!| |}}
{{familytree | | | | | | | F01 | |F01=Intolerant to ACE-I}}
{{familytree | | | | | |,|-|^|-|.| |}}
{{familytree | | | | | G01 | | G02 | |G01=[[Cough]]|G02=[[Renal insufficiency]] or [[angioedema]]}}
{{familytree | | | | | |!| | | |!| |}}
{{familytree | | | | | H01 | | H02 | |H01=[[Angiotensin II receptor antagonist|ARBs]]|H02=[[Hydralazine]]/[[isosorbide dinitrate]]<ref name="pmid3520315">{{cite journal| author=Cohn JN, Archibald DG, Ziesche S, Franciosa JA, Harston WE, Tristani FE et al.| title=Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative Study. | journal=N Engl J Med | year= 1986 | volume= 314 | issue= 24 | pages= 1547-52 | pmid=3520315 | doi=10.1056/NEJM198606123142404 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3520315 }} </ref>}}
{{familytree | | | | | |`|-|v|-|'| |}}
{{familytree | | | | | | | I01 | | | I01=Persistent symptoms?}}
{{familytree | | | | | |,|-|^|-|.| |}}
{{familytree | | | | | J01 | | J02 | J01='''Yes'''|J02='''No'''}}
{{familytree | | | | | |!| | | |!| | }}
{{familytree | | | | | K01 | | |!| | K01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Add:''' 
❑ [[Aldosterone]] or [[eplerenone]] if: 
:❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
:❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
:❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
:❑ NYHA class II–IV HF with LVEF ≤ 35% '''OR''' 
❑ [[Hydralazine]]/[[isosorbide dinitrate]] 
:❑ African Americans with NYHA class III–IV HFrEF on GDMT '''OR''' 
❑ [[ARBs]]<ref name="pmid13678868">{{cite journal| author=Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, Michelson EL et al.| title=Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme. | journal=Lancet | year= 2003 | volume= 362 | issue= 9386 | pages= 759-66 | pmid=13678868 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13678868 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15122853 Review in: ACP J Club. 2004 Mar-Apr;140(2):32-3] </ref>

</div>}}
{{familytree | | | | | |!| | | |!| | |}}
{{familytree | | | | | L01 | | |!| | |L01=Persistent symptoms?}}
{{familytree | | | | | |!| | | |!| |}}
{{familytree | | | | | M01 | | |!| |M01=Add [[digoxin]] }}
{{familytree | | | | | |!| | | |!| | |}}
{{familytree | | | | | N01 | | |!| | |N01=Persistent symptoms?}}
{{familytree | | | |,|-|^|-|.| |!| | }}
{{familytree | | | O01 | | O02 |!| | |O01='''Yes'''|O02='''No'''}}
{{familytree | | | |!| | | |`|-|^|-|.| | |}}
{{familytree | | | P01 | | | | | | P02 | | | | P01=<div style="float: left; text-align: left; width: 15em; padding:1em;">
❑ LVEF ≤ 35% 
❑ Sinus rhythm or [[Left bundle branch block|LBBB]] 
❑ [[Chronic heart failure resident survival guide#New York Heart Association (NYHA)|NYHA]] III - IV </div>|P02=LVEF ≤ 35%?}}
{{familytree | |,|-|^|-|.| | | |,|-|^|-|.| | |}}
{{familytree | Q01 | | Q02 | | Q03 | | Q04 | | |Q01='''Yes'''|Q02='''No'''|Q03='''Yes'''|Q04='''No'''}}
{{familytree | |!| | | |!| | | |!| | | |!| |}}
{{familytree | R01 | | |!| | | R02 | | R03 | |R01=[[Cardiac resynchronization therapy]] (CRT) ± [[Implantable cardioverter defibrillator]] (ICD)|R02=<div style="float: left; text-align: left; width: 15em; padding:1em;">[[Implantable cardioverter defibrillator]] 
❑ As primary prevention of [[sudden cardiac death]] in:
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT </div>|R03=Continue GDMT}}
{{familytree | |`|-|v|-|'| | |}}
{{familytree | | | S01 | | |S01=Persistent symptoms (Advanced heart failure)}}
{{familytree | | | |!| | |}}
{{familytree | | | T01 | |T01=IV inotropes or vasodilators }}
{{familytree | | | |!| | |}}
{{familytree | | | U01 | | U01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''[[Mechanical circulatory support]] (MCS)<ref name="pmid21300961">{{cite journal| author=Naidu SS| title=Novel percutaneous cardiac assist devices: the science of and indications for hemodynamic support. | journal=Circulation | year= 2011 | volume= 123 | issue= 5 | pages= 533-43 | pmid=21300961 | doi=10.1161/CIRCULATIONAHA.110.945055 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21300961 }} </ref>:''' 
* [[Intra-aortic balloon pump]] 
* [[Ventricular assist device|LVAD]] - as bridge to recovery,<ref name="pmid17079761">{{cite journal| author=Birks EJ, Tansley PD, Hardy J, George RS, Bowles CT, Burke M et al.| title=Left ventricular assist device and drug therapy for the reversal of heart failure. | journal=N Engl J Med | year= 2006 | volume= 355 | issue= 18 | pages= 1873-84 | pmid=17079761 | doi=10.1056/NEJMoa053063 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17079761 }} </ref> transplant, or as definitive therapy<ref name="pmid19920051">{{cite journal| author=Slaughter MS, Rogers JG, Milano CA, Russell SD, Conte JV, Feldman D et al.| title=Advanced heart failure treated with continuous-flow left ventricular assist device. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 23 | pages= 2241-51 | pmid=19920051 | doi=10.1056/NEJMoa0909938 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19920051 }} </ref> 
❑ General indications:
:❑ LVEF ≤ 25% 
:❑ NYHA III or IV on chronic GDMT 
:❑ Predicted 1-2 year mortality</div>|R03=Continue GDMT</div>}}
{{familytree | | | |!| |}}
{{familytree | | | V01 | V01=[[Heart transplantation|Cardiac transplantation]]}}
{{familytree/end}}

====Diuretic Therapy====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Commence IV [[diuretics]] 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients</div> 
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 

----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ DVT prophylaxis</div>}}
{{familytree/end}}

==== Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily doses, maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice, 600 mg max daily dose In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice, 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once, 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice, 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice, 200 mg
|-
| || [[Metolazone]] || 2.5 mg once, 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once, 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once, 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice, 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice, 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once, 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once, 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once, 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice, 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once, 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice, 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once, 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once, 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once, 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated, max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated, max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion, maximum of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily, 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily
|}

==Do's==
* Ensure guideline-directed medical therapy (GDMT) - This is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible if no recent one available or if the patient's clinical status is deteriorating.
* Digitalis decreases hospitalization but not mortality. It can be beneficial in symptomatic patients with low EF.<ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an
episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* Make sure your patient is on [[DVT]] prophylaxis unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

Advanced heart failure refers to severe symptoms of heart failure with [[dyspnea]] and/or [[fatigue]] at rest or with minimal exertion (NYHA class III or IV). These parameters assist in identifying patients with advanced heart failure:
<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref>

* Repeated (≥2) hospitalizations or ED visits for HF in the past year
* Progressive deterioration in renal function (eg, rise in BUN and [[creatinine]])
* Weight loss without other cause (eg, cardiac cachexia)
* Intolerance to ACE inhibitors due to [[hypotension]] and/or worsening renal function
* Intolerance to beta blockers due to worsening HF or hypotension
* Frequent systolic blood pressure <90 mm Hg
* Persistent [[dyspnea]] with dressing or bathing requiring rest
* Inability to walk 1 block on the level ground due to dyspnea or fatigue
* Recent need to escalate diuretics to maintain volume status, often reaching daily [[furosemide]] equivalent dose over 160 mg/d and/or use of supplemental [[metolazone]] therapy
* Progressive decline in serum sodium, usually to < 133 mEq/L
* Frequent ICD shocks

==Don'ts==
* Avoid the use of [[NSAIDs]], sympathomimetics, [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine calcium channel blockers ([[diltiazem]], [[verapamil]].<ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't Use parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal functions worsening and hyperkalemia.
* Avoid using [[statins]] solely for [[heart failure]]. It adds no benefit.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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[[Category:Resident survival guide]]
[[Category:Signs and symptoms]]
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Heart failure resident survival guide

2014-05-09T15:41:22Z

Ayokunle Olubaniyi: /* Treatment */

<div style="width: 80%;">
__NOTOC__
'''For acute heart failure prevention click [[Acute heart failure prevention|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
{{familytree | | | |!| |}}
{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
{{familytree | |!| | | |!| | |}}
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
{{familytree | | | |!| | | |!| | | |}}
{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree/end}}

==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

{{familytree/start}}
{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
{{familytree | | | | | | | | |!| | | | | |}}
{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
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{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
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{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
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{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
{{familytree/end}}

==Treatment==
The treatment of acute heart failure is largely dependent on whether the patient has a preserved [[ejection fraction]] ([[diastolic heart failure]]) or reduced [[ejection fraction]] ([[systolic dysfunction|systolic heart failure]])

{{familytree/start}}
{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
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{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
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{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
[[Atrial fibrillation]] and [[acute decompensated heart failure]] are intimately related; the successful management of [[atrial fibrillation]] is often critical to the success of reversing the acute decompensation. 
'''Points to note''': 
❑ Rate control of [[atrial fibrillation]] is the mainstay of arrhythmia therapy. 
:❑ IV [[diltiazem]] (has no negative inotropic effect) at a loading dose of 0.25 mg/kg over 2 min and maintenance dose of 5 to 15 mg/h 
:❑ IV short acting [[esmolol]] at a loading dose of 500 mcg/kg over 1 min and maintenance dose at 60 to 200 mcg/kg/min 
Avoid the use of drugs with negative inotropic effects such as [[beta blockers]] and non-dihydropyridine [[calcium channel blockers]] e.g., [[verapamil]] in the treatment of acute decompensated [[systolic dysfunction|systolic heart failure]] 
❑ Consider [[cardioversion]] 
:❑ If the patient is in [[cardiogenic shock]] 
:❑ If new onset [[atrial fibrillation]] is the clear precipitant of the hemodynamic decompensation 
'''Note''': [[Unfractionated heparin]] should be administered before [[cardioversion]] 
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
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{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
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{{familytree | | | | | | | | J01 | | |J01='''Classify the patient based on the left ventricular ejection fraction'''}}
{{familytree | | | | | | |,|-|^|-|.| | |}}
{{familytree | | | | | | K01 | | K02 | |K01='''Diastolic heart failure LVEF ≥ 50%'''|K02='''Systolic heart failure LVEF ≤ 40%'''}}
{{familytree | | | | | | |!| | | |!| | |}}
{{familytree | | | | | | X01 | | X02 | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
❑ Rate control - to prolong left ventricular filling time 
:❑ Administer [[beta blockers]], especially in the setting of [[atrial fibrillation]] 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] to reduce volume overload (click for details) 
Avoid excess diuresis in patients with diastolic heart failure as they are prone to hypotension due to reductions in preload ❑ Relief of [[ischemia]] 
:❑ [[Coronary revascularization]] in the setting of [[angina]] and demonstrable [[myocardial ischemia]] 
❑ The use of inotropes such as [[dobutamine]], [[milrinone]] is not indicated </div>|X02=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
'''Consider the following:''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] (click for details) 
❑ IV [[vasodilators]] 
❑ Inotropic therapy 
❑ Vasopressor support 
❑ [[ACE inhibitors]] 
ACE inhibitor should not be initiated within the first 12 to 24 hours of acute decompensation of heart failure as these agents may result in prolonged hypotension and impaired end organ perfusion 
It can be continued in: 
:❑ Hemodynamically stable patients with [[acute decompensated heart failure]] without a rising [[creatinine]] or [[hyperkalemia]] 
❑ [[Beta blockers]]<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> 
Beta blockers should not be initiated during acute decompensated heart failure 
It can be continued in: 
:❑ A patient chronically on [[beta blockers]] in the absence of [[hypotension]] 
❑ [[Aldosterone antagonists]] 
It can be continued in: 
:❑ A patients chronically on [[aldosterone antagonists]] prior to the development of [[acute decompensated heart failure]] in the absence of [[hypotension]], [[hyperkalemia]], and [[impaired renal function]] </div>}}
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{{familytree | | | | | | | | L01 | |L01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventricular tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
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{{familytree | | | | | | | | M01 | |M01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[cardiac transplantation]]''' 
----
❑ Refractory [[cardiogenic shock]] 
❑ Documented dependence on intravenous inotropic support to maintain adequate organ perfusion 
❑ Peak VO2 less than 10 mL/kg per min with achievement of anaerobic metabolism 
</div>}}
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{{familytree | | | | | | | | N01 | |N01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' prior to discharge 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Aldosterone antagonists]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
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{{familytree | | | | | | | | O01 | |O01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
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{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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</div>

Heart failure resident survival guide

2014-05-09T15:38:53Z

Ayokunle Olubaniyi: /* Treatment */

<div style="width: 80%;">
__NOTOC__
'''For acute heart failure prevention click [[Acute heart failure prevention|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
{{familytree | | | |!| |}}
{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
{{familytree | |!| | | |!| | |}}
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
{{familytree | | | |!| | | |!| | | |}}
{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree/end}}

==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

{{familytree/start}}
{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
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{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
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{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
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{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
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{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
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{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
{{familytree/end}}

==Treatment==
The treatment of acute heart failure is largely dependent on whether the patient has a preserved [[ejection fraction]] ([[diastolic heart failure]]) or reduced [[ejection fraction]] ([[systolic dysfunction|systolic heart failure]])

{{familytree/start}}
{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
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{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
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{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
[[Atrial fibrillation]] and [[acute decompensated heart failure]] are intimately related; the successful management of [[atrial fibrillation]] is often critical to the success of reversing the acute decompensation. 
'''Points to note''': 
❑ Rate control of [[atrial fibrillation]] is the mainstay of arrhythmia therapy. 
:❑ IV [[diltiazem]] (has no negative inotropic effect) at a loading dose of 0.25 mg/kg over 2 min and maintenance dose of 5 to 15 mg/h 
:❑ IV short acting [[esmolol]] at a loading dose of 500 mcg/kg over 1 min and maintenance dose at 60 to 200 mcg/kg/min 
Avoid the use of drugs with negative inotropic effects such as [[beta blockers]] and non-dihydropyridine [[calcium channel blockers]] e.g., [[verapamil]] in the treatment of acute decompensated [[systolic dysfunction|systolic heart failure]] 
❑ Consider [[cardioversion]] 
:❑ If the patient is in [[cardiogenic shock]] 
:❑ If new onset [[atrial fibrillation]] is the clear precipitant of the hemodynamic decompensation 
'''Note''': [[Unfractionated heparin]] should be administered before [[cardioversion]] 
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
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{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
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{{familytree | | | | | | | | J01 | | |J01='''Classify the patient based on the left ventricular ejection fraction'''}}
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{{familytree | | | | | | K01 | | K02 | |K01='''Diastolic heart failure LVEF ≥ 50%'''|K02='''Systolic heart failure LVEF ≤ 40%'''}}
{{familytree | | | | | | |!| | | |!| | |}}
{{familytree | | | | | | X01 | | X02 | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
❑ Rate control - to prolong left ventricular filling time 
:❑ Administer [[beta blockers]], especially in the setting of [[atrial fibrillation]] 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] to reduce volume overload (click for details) 
Avoid excess diuresis in patients with diastolic heart failure as they are prone to hypotension due to reductions in preload ❑ Relief of [[ischemia]] 
:❑ [[Coronary revascularization]] in the setting of [[angina]] and demonstrable [[myocardial ischemia]] 
❑ The use of inotropes such as [[dobutamine]], [[milrinone]] is not indicated </div>|X02=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
'''Consider the following:''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] (click for details) 
❑ IV [[vasodilators]] 
❑ Inotropic therapy 
❑ Vasopressor support 
❑ [[ACE inhibitors]] 
ACE inhibitor should not be initiated within the first 12 to 24 hours of acute decompensation of heart failure as these agents may result in prolonged hypotension and impaired end organ perfusion 
It can be continued in: 
:❑ Hemodynamically stable patients with [[acute decompensated heart failure]] without a rising [[creatinine]] or [[hyperkalemia]] 
❑ [[Beta blockers]]<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> 
Beta blockers should not be initiated during acute decompensated heart failure 
It can be continued in: 
:❑ A patient chronically on [[beta blockers]] in the absence of [[hypotension]] 
❑ [[Aldosterone antagonists]] 
It can be continued in: 
:❑ A patients chronically on [[aldosterone antagonists]] prior to the development of [[acute decompensated heart failure]] in the absence of [[hypotension]], [[hyperkalemia]], and [[impaired renal function]] </div>}}
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{{familytree | | | | | | | | L01 | |L01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventricular tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
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{{familytree | | | | | | | | M01 | |M01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[cardiac transplantation]]''' 
----
❑ Refractory [[cardiogenic shock]] 
❑ Documented dependence on intravenous inotropic support to maintain adequate organ perfusion 
❑ Peak VO2 less than 10 mL/kg per min with achievement of anaerobic metabolism 
</div>}}
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{{familytree | | | | | | | | N01 | |N01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' prior to discharge 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Aldosterone antagonists]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
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{{familytree | | | | | | | | O01 | |O01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
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====Diuretic Therapy Details====
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{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
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{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
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{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
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{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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[[Category:Resident survival guide]]
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</div>

Heart failure resident survival guide

2014-05-08T09:51:58Z

Ayokunle Olubaniyi: /* Treatment */

<div style="width: 80%;">
__NOTOC__
'''For acute heart failure prevention click [[Acute heart failure prevention|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
{{familytree | | | |!| |}}
{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
{{familytree | |!| | | |!| | |}}
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
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{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
{{familytree | | | |!| | | |!| | | |}}
{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
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==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

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{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
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{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
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{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
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{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
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{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
{{familytree | | | | | | |,|-|^|-|.| | | | | |}}
{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
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==Treatment==
The treatment of acute heart failure is largely dependent on whether the patient has a preserved [[ejection fraction]] ([[diastolic heart failure]]) or reduced [[ejection fraction]] ([[systolic dysfunction|systolic heart failure]])

{{familytree/start}}
{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
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{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
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{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
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{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | J01 | | |J01='''Classify the patient based on the left ventricular ejection fraction'''}}
{{familytree | | | | | | |,|-|^|-|.| | |}}
{{familytree | | | | | | K01 | | K02 | |K01='''Diastolic heart failure LVEF ≥ 50%'''|K02='''Systolic heart failure LVEF ≤ 40%'''}}
{{familytree | | | | | | |!| | | |!| | |}}
{{familytree | | | | | | X01 | | X02 | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
❑ Rate control - to prolong left ventricular filling time 
:❑ Administer [[beta blockers]], especially in the setting of [[atrial fibrillation]] 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] to reduce volume overload (click for details) 
Avoid excess diuresis in patients with diastolic heart failure as they are prone to hypotension due to reductions in preload ❑ Relief of [[ischemia]] 
:❑ [[Coronary revascularization]] in the setting of [[angina]] and demonstrable [[myocardial ischemia]] 
❑ The use of inotropes such as [[dobutamine]], [[milrinone]] is not indicated </div>|X02=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
'''Consider the following:''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] (click for details) 
❑ IV [[vasodilators]] 
❑ Inotropic therapy 
❑ Vasopressor support 
❑ [[ACE inhibitors]] 
ACE inhibitor should not be initiated within the first 12 to 24 hours of acute decompensation of heart failure as these agents may result in prolonged hypotension and impaired end organ perfusion 
It can be continued in: 
:❑ Hemodynamically stable patients with [[acute decompensated heart failure]] without a rising [[creatinine]] or [[hyperkalemia]] 
❑ [[Beta blockers]]<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> 
Beta blockers should not be initiated during acute decompensated heart failure 
It can be continued in: 
:❑ A patient chronically on [[beta blockers]] in the absence of [[hypotension]] 
❑ [[Aldosterone antagonists]] 
It can be continued in: 
:❑ A patients chronically on [[aldosterone antagonists]] prior to the development of [[acute decompensated heart failure]] in the absence of [[hypotension]], [[hyperkalemia]], and [[impaired renal function]] </div>}}
{{familytree | | | | | | |`|-|v|-|'| | | |}}
{{familytree | | | | | | | | L01 | |L01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventricular tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | M01 | |M01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[cardiac transplantation]]''' 
----
❑ Refractory [[cardiogenic shock]] 
❑ Documented dependence on intravenous inotropic support to maintain adequate organ perfusion 
❑ Peak VO2 less than 10 mL/kg per min with achievement of anaerobic metabolism 
</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | N01 | |N01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' prior to discharge 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Aldosterone antagonists]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | O01 | |O01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

[[Category:Disease]]
[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Primary care]]
[[Category:Resident survival guide]]
[[Category:Signs and symptoms]]
[[Category:Cardiology]]
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[[Category:Up-To-Date cardiology]]
[[Category:Intensive care medicine]]

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</div>

Heart failure resident survival guide

2014-05-07T20:37:18Z

Ayokunle Olubaniyi: /* Treatment */

<div style="width: 80%;">
__NOTOC__
'''For acute heart failure prevention click [[Acute heart failure prevention|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
{{familytree | | | |!| |}}
{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
{{familytree | |!| | | |!| | |}}
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
{{familytree | | | |!| | | |!| | | |}}
{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree/end}}

==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

{{familytree/start}}
{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
{{familytree | | | | | | | | |!| | | | | |}}
{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
{{familytree | | | | | | |,|-|^|-|.| | | | | |}}
{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
{{familytree/end}}

==Treatment==
The treatment of acute heart failure is largely dependent on whether the patient has a preserved [[ejection fraction]] ([[diastolic heart failure]]) or reduced [[ejection fraction]] ([[systolic dysfunction|systolic heart failure]])

{{familytree/start}}
{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
{{familytree | | | | | | | | |!| | | |}}
{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
{{familytree | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | J01 | | |J01='''Classify the patient based on the left ventricular ejection fraction'''}}
{{familytree | | | | | | |,|-|^|-|.| | |}}
{{familytree | | | | | | K01 | | K02 | |K01='''Diastolic heart failure LVEF ≥ 50%'''|K02='''Systolic heart failure LVEF ≤ 40%'''}}
{{familytree | | | | | | |!| | | |!| | |}}
{{familytree | | | | | | X01 | | X02 | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
❑ Rate control - to prolong left ventricular filling time 
:❑ Administer [[beta blockers]], especially in the setting of [[atrial fibrillation]] 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] to reduce volume overload (click for details) 
Avoid excess diuresis in patients with diastolic heart failure as they are prone to hypotension due to reductions in preload ❑ Relief of [[ischemia]] 
:❑ [[Coronary revascularization]] in the setting of [[angina]] and demonstrable [[myocardial ischemia]] 
❑ The use of inotropes such as [[dobutamine]], [[milrinone]] is not indicated </div>|X02=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
'''Consider the following:''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] (click for details) 
❑ IV [[vasodilators]] 
❑ Inotropic therapy 
❑ Vasopressor support 
❑ [[ACE inhibitors]] 
ACE inhibitor should not be initiated within the first 12 to 24 hours of acute decompensation of heart failure as these agents may result in prolonged hypotension and impaired end organ perfusion 
You may consider in: 
:❑ Hemodynamically stable patients with [[acute decompensated heart failure]] without a rising [[creatinine]] or [[hyperkalemia]] 
❑ [[Beta blockers]]<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> 
Beta blockers should not be initiated during acute decompensated heart failure 
It can be continued in: 
:❑ A patient chronically on [[beta blockers]] in the absence of [[hypotension]] 
❑ [[Aldosterone antagonists]] 
It can be continued in: 
:❑ A patients chronically on [[aldosterone antagonists]] prior to the development of [[acute decompensated heart failure]] in the absence of [[hypotension]], [[hyperkalemia]], and [[impaired renal function]] </div>}}
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{{familytree | | | | | | | | L01 | |L01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventricular tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | M01 | |M01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[cardiac transplantation]]''' 
----
❑ Refractory [[cardiogenic shock]] 
❑ Documented dependence on intravenous inotropic support to maintain adequate organ perfusion 
❑ Peak VO2 less than 10 mL/kg per min with achievement of anaerobic metabolism 
</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | N01 | |N01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' prior to discharge 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Aldosterone antagonists]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | O01 | |O01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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[[Category:Resident survival guide]]
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[[Category:Intensive care medicine]]

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</div>

Heart failure resident survival guide

2014-05-07T20:32:27Z

Ayokunle Olubaniyi: /* Treatment */

<div style="width: 80%;">
__NOTOC__
'''For acute heart failure prevention click [[Acute heart failure prevention|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
{{familytree | | | |!| |}}
{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
{{familytree | |!| | | |!| | |}}
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
{{familytree | | | |!| | | |!| | | |}}
{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree/end}}

==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

{{familytree/start}}
{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
{{familytree | | | | | | | | |!| | | | | |}}
{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
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{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
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{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
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{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
{{familytree/end}}

==Treatment==
The treatment of acute heart failure is largely dependent on whether the patient has a preserved [[ejection fraction]] ([[diastolic heart failure]]) or reduced [[ejection fraction]] ([[systolic dysfunction|systolic heart failure]])

{{familytree/start}}
{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
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{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
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{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
{{familytree | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | J01 | | |J01='''Classify the patient based on the left ventricular ejection fraction'''}}
{{familytree | | | | | | |,|-|^|-|.| | |}}
{{familytree | | | | | | K01 | | K02 | |K01='''Diastolic heart failure LVEF ≥ 50%'''|K02='''Systolic heart failure LVEF ≤ 40%'''}}
{{familytree | | | | | | |!| | | |!| | |}}
{{familytree | | | | | | X01 | | X02 | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
❑ Rate control - to prolong left ventricular filling time 
:❑ Administer [[beta blockers]], especially in the setting of [[atrial fibrillation]] 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] to reduce volume overload (click for details) 
Avoid excess diuresis in patients with diastolic heart failure as they are prone to hypotension due to reductions in preload ❑ Relief of [[ischemia]] 
:❑ [[Coronary revascularization]] in the setting of [[angina]] and demonstrable [[myocardial ischemia]] 
❑ The use of inotropes such as [[dobutamine]], [[milrinone]] is not indicated </div>|X02=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
'''Consider the following:''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] (click for details) 
❑ IV [[vasodilators]] 
❑ Inotropic therapy 
❑ Vasopressor support 
❑ [[ACE inhibitors]] 
ACE inhibitor should not be initiated within the first 12 to 24 hours of acute decompensation of heart failure as these agents may result in prolonged hypotension and impaired end organ perfusion 
You may consider in: 
:❑ Hemodynamically stable patients with [[acute decompensated heart failure]] without a rising [[creatinine]] or [[hyperkalemia]] 
❑ [[Beta blockers]]<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> 
Beta blockers should not be initiated during acute decompensated heart failure 
It can be continued in: 
:❑ A patient chronically on [[beta blockers]] in the absence of [[hypotension]] 
❑ [[Aldosterone antagonists]] 
It can be continued in: 
:❑ A patients chronically on [[aldosterone antagonists]] prior to the development of [[acute decompensated heart failure]] in the absence of [[hypotension]], [[hyperkalemia]], and [[impaired renal function]] </div>}}
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{{familytree | | | | | | | | L01 | |L01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
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{{familytree | | | | | | | | M01 | |M01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[cardiac transplantation]]''' 
----
❑ Refractory [[cardiogenic shock]] 
❑ Documented dependence on intravenous inotropic support to maintain adequate organ perfusion 
❑ Peak VO2 less than 10 mL/kg per min with achievement of anaerobic metabolism 
</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | N01 | |N01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' prior to discharge 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Aldosterone antagonists]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
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{{familytree | | | | | | | | O01 | |O01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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</div>

Heart failure resident survival guide

2014-05-07T20:28:17Z

Ayokunle Olubaniyi: /* Treatment */

<div style="width: 80%;">
__NOTOC__
'''For acute heart failure prevention click [[Acute heart failure prevention|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
{{familytree | | | |!| |}}
{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
{{familytree | |!| | | |!| | |}}
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
{{familytree | | | |!| | | |!| | | |}}
{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree/end}}

==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

{{familytree/start}}
{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
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{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
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{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
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{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
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{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
{{familytree/end}}

==Treatment==
The treatment of acute heart failure is largely dependent on whether the patient has a preserved [[ejection fraction]] ([[diastolic heart failure]]) or reduced [[ejection fraction]] ([[systolic dysfunction|systolic heart failure]])

{{familytree/start}}
{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
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{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
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{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
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{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
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{{familytree | | | | | | | | J01 | | |J01='''Classify the patient based on the left ventricular ejection fraction'''}}
{{familytree | | | | | | |,|-|^|-|.| | |}}
{{familytree | | | | | | K01 | | K02 | |K01='''Diastolic heart failure LVEF ≥ 50%'''|K02='''Systolic heart failure LVEF ≤ 40%'''}}
{{familytree | | | | | | |!| | | |!| | |}}
{{familytree | | | | | | X01 | | X02 | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
❑ Rate control - to prolong left ventricular filling time 
:❑ Administer [[beta blockers]], especially in the setting of [[atrial fibrillation]] 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] to reduce volume overload 
❑ Relief of [[ischemia]] 
:❑ [[Coronary revascularization]] in the setting of [[angina]] and demonstrable [[myocardial ischemia]] 
❑ The use of inotropes such as [[dobutamine]], [[milrinone]] is not indicated </div>|X02=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
'''Consider the following:''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] 
Avoid excess diuresis in patients with diastolic heart failure as they are prone to hypotension due to reductions in preload 
❑ IV [[vasodilators]] 
❑ Inotropic therapy 
❑ Vasopressor support 
❑ [[ACE inhibitors]] 
ACE inhibitor should not be initiated within the first 12 to 24 hours of acute decompensation of heart failure as these agents may result in prolonged hypotension and impaired end organ perfusion 
You may consider in: 
:❑ Hemodynamically stable patients with [[acute decompensated heart failure]] without a rising [[creatinine]] or [[hyperkalemia]] 
❑ [[Beta blockers]]<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> 
Beta blockers should not be initiated during acute decompensated heart failure 
It can be continued in: 
:❑ A patient chronically on [[beta blockers]] in the absence of [[hypotension]] 
❑ [[Aldosterone antagonists]] 
It can be continued in: 
:❑ A patients chronically on [[aldosterone antagonists]] prior to the development of [[acute decompensated heart failure]] in the absence of [[hypotension]], [[hyperkalemia]], and [[impaired renal function]] </div>}}
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{{familytree | | | | | | | | L01 | |L01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
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{{familytree | | | | | | | | M01 | |M01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[cardiac transplantation]]''' 
----
❑ Refractory [[cardiogenic shock]] 
❑ Documented dependence on intravenous inotropic support to maintain adequate organ perfusion 
❑ Peak VO2 less than 10 mL/kg per min with achievement of anaerobic metabolism 
</div>}}
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{{familytree | | | | | | | | N01 | |N01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' prior to discharge 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Aldosterone antagonists]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
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{{familytree | | | | | | | | O01 | |O01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
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====Diuretic Therapy Details====
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{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
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{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
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{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
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{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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</div>

Heart failure resident survival guide

2014-05-07T20:24:21Z

Ayokunle Olubaniyi: /* Treatment */

<div style="width: 80%;">
__NOTOC__
'''For acute heart failure prevention click [[Acute heart failure prevention|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
{{familytree | | | |!| |}}
{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
{{familytree | |!| | | |!| | |}}
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
{{familytree | | | |!| | | |!| | | |}}
{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
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==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

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{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
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{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
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{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
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{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
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{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
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{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
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==Treatment==
The treatment of acute heart failure is largely dependent on whether the patient has a preserved [[ejection fraction]] ([[diastolic heart failure]]) or reduced [[ejection fraction]] ([[systolic dysfunction|systolic heart failure]])

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{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
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{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
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{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
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{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
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{{familytree | | | | | | | | J01 | | |J01='''Classify the patient based on the left ventricular ejection fraction'''}}
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{{familytree | | | | | | K01 | | K02 | |K01='''Diastolic heart failure LVEF ≥ 50%'''|K02='''Systolic heart failure LVEF ≤ 40%'''}}
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{{familytree | | | | | | X01 | | X02 | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
❑ Rate control - to prolong left ventricular filling time 
:❑ Administer [[beta blockers]], especially in the setting of [[atrial fibrillation]] 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] to reduce volume overload 
❑ Relief of [[ischemia]] 
:❑ [[Coronary revascularization]] in the setting of [[angina]] and demonstrable [[myocardial ischemia]] 
❑ The use of inotropes such as [[dobutamine]], [[milrinone]] is not indicated </div>|X02=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
'''Consider the following:''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] 
Avoid excess diuresis in patients with diastolic heart failure as they are prone to hypotension due to reductions in preload 
❑ IV [[vasodilators]] 
❑ Inotropic therapy 
❑ Vasopressor support 
❑ [[ACE inhibitors]] 
ACE inhibitor should not be initiated within the first 12 to 24 hours of acute decompensation of heart failure as these agents may result in prolonged hypotension and impaired end organ perfusion 
You may consider in: 
:❑ Hemodynamically stable patients with [[acute decompensated heart failure]] without a rising [[creatinine]] or [[hyperkalemia]] 
❑ [[Beta blockers]]<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> 
Beta blockers should not be initiated during acute decompensated heart failure 
It can be continued in: 
:❑ A patient chronically on [[beta blockers]] in the absence of [[hypotension]] 
❑ [[Aldosterone antagonists]] 
It can be continued in: 
:❑ A patients chronically on [[aldosterone antagonists]] prior to the development of [[acute decompensated heart failure]] in the absence of [[hypotension]], [[hyperkalemia]], and [[impaired renal function]] </div>}}
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{{familytree | | | | | | | | L01 | |L01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
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{{familytree | | | | | | | | M01 | |M01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[cardiac transplantation]]''' 
----
❑ 
:❑ 
:❑ 
:❑ 
'''Contraindications''' 
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
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{{familytree | | | | | | | | N01 | |N01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' prior to discharge 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Aldosterone antagonists]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | O01 | |O01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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</div>

Heart failure resident survival guide

2014-05-07T20:14:14Z

Ayokunle Olubaniyi: /* Treatment */

<div style="width: 80%;">
__NOTOC__
'''For acute heart failure prevention click [[Acute heart failure prevention|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
{{familytree | | | |!| |}}
{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
{{familytree | |!| | | |!| | |}}
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
{{familytree | | | |!| | | |!| | | |}}
{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree/end}}

==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

{{familytree/start}}
{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
{{familytree | | | | | | | | |!| | | | | |}}
{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
{{familytree | | | | | | |,|-|^|-|.| | | | | |}}
{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
{{familytree/end}}

==Treatment==
The treatment of acute heart failure is largely dependent on whether the patient has a preserved [[ejection fraction]] ([[diastolic heart failure]]) or reduced [[ejection fraction]] ([[systolic dysfunction|systolic heart failure]])

{{familytree/start}}
{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
{{familytree | | | | | | | | |!| | | |}}
{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
{{familytree | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | J01 | | |J01='''Classify the patient based on the left ventricular ejection fraction'''}}
{{familytree | | | | | | |,|-|^|-|.| | |}}
{{familytree | | | | | | K01 | | K02 | |K01='''Diastolic heart failure LVEF ≥ 50%'''|K02='''Systolic heart failure LVEF ≤ 40%'''}}
{{familytree | | | | | | |!| | | |!| | |}}
{{familytree | | | | | | X01 | | X02 | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
❑ Rate control - to prolong left ventricular filling time 
:❑ Administer [[beta blockers]], especially in the setting of [[atrial fibrillation]] 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] to reduce volume overload 
❑ Relief of [[ischemia]] 
:❑ [[Coronary revascularization]] in the setting of [[angina]] and demonstrable [[myocardial ischemia]] 
❑ The use of inotropes such as [[dobutamine]], [[milrinone]] is not indicated </div>|X02=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
'''Consider the following:''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] 
❑ IV [[vasodilators]] 
❑ Inotropic therapy 
❑ Vasopressor support 
❑ [[ACE inhibitors]] 
ACE inhibitor should not be initiated within the first 12 to 24 hours of acute decompensation of heart failure as these agents may result in prolonged hypotension and impaired end organ perfusion 
You may consider in: 
:❑ Hemodynamically stable patients with [[acute decompensated heart failure]] without a rising [[creatinine]] or [[hyperkalemia]] 
❑ [[Beta blockers]]<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> 
Beta blockers should not be initiated during acute decompensated heart failure 
It can be continued in: 
:❑ A patient chronically on [[beta blockers]] in the absence of [[hypotension]] 
❑ [[Aldosterone antagonists]] 
It can be continued in: 
:❑ A patients chronically on [[aldosterone antagonists]] prior to the development of [[acute decompensated heart failure]] in the absence of [[hypotension]], [[hyperkalemia]], and [[impaired renal function]] </div>}}
{{familytree | | | | | | |`|-|v|-|'| | | |}}
{{familytree | | | | | | | | L01 | |L01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | M01 | |M01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[cardiac transplantation]]''' 
----
❑ 
:❑ 
:❑ 
:❑ 
'''Contraindications''' 
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | N01 | |N01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' prior to discharge 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Aldosterone antagonists]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | O01 | |O01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

[[Category:Disease]]
[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Primary care]]
[[Category:Resident survival guide]]
[[Category:Signs and symptoms]]
[[Category:Cardiology]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date cardiology]]
[[Category:Intensive care medicine]]

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</div>

Heart failure resident survival guide

2014-05-07T20:05:38Z

Ayokunle Olubaniyi: /* Treatment */

<div style="width: 80%;">
__NOTOC__
'''For acute heart failure prevention click [[Acute heart failure prevention|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
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! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
{{familytree | | | |!| |}}
{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
{{familytree | |!| | | |!| | |}}
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
{{familytree | | | |!| | | |!| | | |}}
{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree/end}}

==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

{{familytree/start}}
{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
{{familytree | | | | | | | | |!| | | | | |}}
{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
{{familytree | | | | | | |,|-|^|-|.| | | | | |}}
{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
{{familytree/end}}

==Treatment==
The treatment of acute heart failure is largely dependent on whether the patient has a preserved [[ejection fraction]] ([[diastolic heart failure]]) or reduced [[ejection fraction]] ([[systolic dysfunction|systolic heart failure]])

{{familytree/start}}
{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
{{familytree | | | | | | | | |!| | | |}}
{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
{{familytree | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | J01 | | |J01='''Classify the patient based on the left ventricular ejection fraction'''}}
{{familytree | | | | | | |,|-|^|-|.| | |}}
{{familytree | | | | | | K01 | | K02 | |K01='''Diastolic heart failure LVEF ≥ 50%'''|K02='''Systolic heart failure LVEF ≤ 40%'''}}
{{familytree | | | | | | |!| | | |!| | |}}
{{familytree | | | | | | X01 | | X02 | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
❑ Rate control - to prolong left ventricular filling time 
:❑ Administer [[beta blockers]], especially in the setting of [[atrial fibrillation]] 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] to reduce volume overload 
❑ Relief of [[ischemia]] 
:❑ [[Coronary revascularization]] in the setting of [[angina]] and demonstrable [[myocardial ischemia]] 
❑ The use of inotropes such as [[dobutamine]], [[milrinone]] is not indicated </div>|X02=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
'''Consider the following:''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] 
❑ IV [[vasodilators]] 
❑ Inotropic therapy 
❑ Vasopressor support 
❑ [[ACE inhibitors]] 
ACE inhibitor should not be initiated within the first 12 to 24 hours of acute decompensation of heart failure as these agents may result in prolonged hypotension and impaired end organ perfusion 
You may consider in: 
:❑ Hemodynamically stable patients with [[acute decompensated congestive heart failure]] without a rising [[creatinine]] or [[hyperkalemia]] 
❑ [[Beta blockers]]<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> 
Beta blockers should not be initiated during acute decompensated heart failure 
It can be continued in: 
:❑ A patient chronically on [[beta blockers]] in the absence of [[hypotension]] 
❑ [[Aldosterone antagonists]] 
It can be continued in: 
:❑ A patients chronically on [[aldosterone antagonists]] prior to the development of [[acute decompensated heart failure]] in the absence of [[hypotension]], [[hyperkalemia]], and [[impaired renal function]] </div>}}
{{familytree | | | | | | |`|-|v|-|'| | | |}}
{{familytree | | | | | | | | L01 | |L01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | M01 | |M01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[cardiac transplantation]]''' 
----
❑ 
:❑ 
:❑ 
:❑ 
'''Contraindications''' 
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | N01 | |N01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' prior to discharge 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Aldosterone antagonists]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | O01 | |O01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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[[Category:Resident survival guide]]
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</div>

Heart failure resident survival guide

2014-05-07T20:02:37Z

Ayokunle Olubaniyi: /* Treatment */

<div style="width: 80%;">
__NOTOC__
'''For acute heart failure prevention click [[Acute heart failure prevention|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
{{familytree | | | |!| |}}
{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
{{familytree | |!| | | |!| | |}}
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
{{familytree | | | |!| | | |!| | | |}}
{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree/end}}

==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

{{familytree/start}}
{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
{{familytree | | | | | | | | |!| | | | | |}}
{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
{{familytree | | | | | | |,|-|^|-|.| | | | | |}}
{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
{{familytree/end}}

==Treatment==
The treatment of acute heart failure is largely dependent on whether the patient has a preserved [[ejection fraction]] ([[diastolic heart failure]]) or reduced [[ejection fraction]] ([[systolic dysfunction|systolic heart failure]])

{{familytree/start}}
{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
{{familytree | | | | | | | | |!| | | |}}
{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
{{familytree | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | J01 | | |J01='''Classify the patient based on the left ventricular ejection fraction'''}}
{{familytree | | | | | | |,|-|^|-|.| | |}}
{{familytree | | | | | | K01 | | K02 | |K01='''Diastolic heart failure LVEF ≥ 50%'''|K02='''Systolic heart failure LVEF ≤ 40%'''}}
{{familytree | | | | | | |!| | | |!| | |}}
{{familytree | | | | | | X01 | | X02 | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
❑ Rate control - to prolong left ventricular filling time 
:❑ Administer [[beta blockers]], especially in the setting of [[atrial fibrillation]] 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] to reduce volume overload 
❑ Relief of [[ischemia]] 
:❑ [[Coronary revascularization]] in the setting of [[angina]] and demonstrable [[myocardial ischemia]] 
❑ The use of inotropes such as [[dobutamine]], [[milrinone]] is not indicated </div>|X02=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
'''Consider the following:''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] 
❑ IV [[vasodilators]] 
❑ Inotropic therapy 
❑ Vasopressor support 
❑ [[ACE inhibitors]]
ACE inhibitor should not be initiated within the first 12 to 24 hours of acute decompensation of heart failure as these agents may result in prolonged hypotension and impaired end organ perfusion 
You may consider in: 
:❑ Hemodynamically stable patients with [[acute decompensated congestive heart failure]] without a rising [[creatinine]] or [[hyperkalemia]]
❑ [[Beta blockers]]<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref>
Beta blockers should not be initiated during acute decompensated heart failure 
It can be continued in: 
:❑ A patient chronically on [[beta blockers]] in the absence of [[hypotension]] 
❑ [[Aldosterone antagonists]] 
It can be continued in: ❑ 
:❑ A patients chronically on [[aldosterone antagonists]] prior to the development of [[acute decompensated heart failure]] in the absence of [[hypotension]], [[hyperkalemia]], and [[impaired renal function]] </div>}}
{{familytree | | | | | | |`|-|v|-|'| | | |}}
{{familytree | | | | | | | | L01 | |L01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | M01 | |M01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[cardiac transplantation]]''' 
----
❑ 
:❑ 
:❑ 
:❑ 
'''Contraindications''' 
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | N01 | |N01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' prior to discharge 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Aldosterone antagonists]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | O01 | |O01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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</div>

Heart failure resident survival guide

2014-05-07T19:00:34Z

Ayokunle Olubaniyi: /* Treatment */

<div style="width: 80%;">
__NOTOC__
'''For acute heart failure prevention click [[Acute heart failure prevention|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
{{familytree | | | |!| |}}
{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
{{familytree | |!| | | |!| | |}}
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
{{familytree | | | |!| | | |!| | | |}}
{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree/end}}

==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

{{familytree/start}}
{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
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{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
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{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
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{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
{{familytree | | | | | | |,|-|^|-|.| | | | | |}}
{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
{{familytree/end}}

==Treatment==
The treatment of acute heart failure is largely dependent on whether the patient has a preserved [[ejection fraction]] ([[diastolic heart failure]]) or reduced [[ejection fraction]] ([[systolic dysfunction|systolic heart failure]])

{{familytree/start}}
{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
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{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
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{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
{{familytree | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | J01 | | |J01='''Classify the patient based on the left ventricular ejection fraction'''}}
{{familytree | | | | | | |,|-|^|-|.| | |}}
{{familytree | | | | | | K01 | | K02 | |K01='''Diastolic heart failure LVEF ≥ 50%'''|K02='''Systolic heart failure LVEF ≤ 40%'''}}
{{familytree | | | | | | |!| | | |!| | |}}
{{familytree | | | | | | X01 | | X02 | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
❑ Rate control - to prolong left ventricular filling time 
:❑ Administer [[beta blockers]], especially in the setting of [[atrial fibrillation]] 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] to reduce volume overload 
❑ Relief of [[ischemia]] 
:❑ [[Coronary revascularization]] in the setting of [[angina]] and demonstrable [[myocardial ischemia]] 
❑ The use of inotropes such as dobutamine, milrinone is not indicated </div>|X02=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
❑ 
❑ 
❑ 
❑ 
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree | | | | | | |`|-|v|-|'| | | |}}
{{familytree | | | | | | | | L01 | |L01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | M01 | |M01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[cardiac transplantation]]''' 
----
❑ 
:❑ 
:❑ 
:❑ 
'''Contraindications''' 
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | N01 | |N01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | O01 | |O01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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</div>

Heart failure resident survival guide

2014-05-07T16:59:54Z

Ayokunle Olubaniyi: /* Treatment */

<div style="width: 80%;">
__NOTOC__
'''For acute heart failure prevention click [[Acute heart failure prevention|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
{{familytree | | | |!| |}}
{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
{{familytree | |!| | | |!| | |}}
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
{{familytree | | | |!| | | |!| | | |}}
{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree/end}}

==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

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{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
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{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
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{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
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{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
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{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
{{familytree | | | | | | |,|-|^|-|.| | | | | |}}
{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
{{familytree/end}}

==Treatment==
The treatment of acute heart failure is largely dependent on whether the patient has a preserved [[ejection fraction]] ([[diastolic heart failure]]) or reduced [[ejection fraction]] ([[systolic dysfunction|systolic heart failure]])

{{familytree/start}}
{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
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{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
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{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
{{familytree | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | J01 | | |J01='''Classify the patient based on the left ventricular ejection fraction'''}}
{{familytree | | | | | | |,|-|^|-|.| | |}}
{{familytree | | | | | | K01 | | K02 | |K01='''Diastolic heart failure LVEF ≥ 50%'''|K02='''Systolic heart failure LVEF ≤ 40%'''}}
{{familytree | | | | | | |!| | | |!| | |}}
{{familytree | | | | | | X01 | | X02 | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
❑ 
❑ 
❑ 
❑ 
❑ 
❑ 
❑ 
❑ 
❑ </div>|X02=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment''' 
----
❑ 
❑ 
❑ 
❑ 
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree | | | | | | |`|-|v|-|'| | | |}}
{{familytree | | | | | | | | L01 | |L01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | M01 | |M01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[cardiac transplantation]]''' 
----
❑ 
:❑ 
:❑ 
:❑ 
'''Contraindications''' 
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | N01 | |N01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | O01 | |O01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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[[Category:Resident survival guide]]
[[Category:Signs and symptoms]]
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</div>

Heart failure resident survival guide

2014-05-07T16:52:10Z

Ayokunle Olubaniyi: /* Treatment */

<div style="width: 80%;">
__NOTOC__
'''For acute heart failure prevention click [[Acute heart failure prevention|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
{{familytree | | | |!| |}}
{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
{{familytree | |!| | | |!| | |}}
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
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{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
{{familytree | | | |!| | | |!| | | |}}
{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree/end}}

==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

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{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
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{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
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{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
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{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
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{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
{{familytree | | | | | | |,|-|^|-|.| | | | | |}}
{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
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==Treatment==
The treatment of acute heart failure is largely dependent on whether the patient has a preserved [[ejection fraction]] ([[diastolic heart failure]]) or reduced [[ejection fraction]] ([[systolic dysfunction|systolic heart failure]])

{{familytree/start}}
{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
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{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
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{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
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{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | J01 | | |J01='''Classify the patient based on the left ventricular ejection fraction'''}}
{{familytree | | | | | | |,|-|^|-|.| | |}}
{{familytree | | | | | | K01 | | K02 | |K01=Diastolic heart failure|K02=Systolic heart failure}}
{{familytree | | | | | | |!| | | |!| | |}}
{{familytree | | | | | | X01 | | X02 | |X01=|X02=}}
{{familytree | | | | | | |`|-|v|-|'| | | |}}
{{familytree | | | | | | | | L01 | |L01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | M01 | |M01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[cardiac transplantation]]''' 
----
❑ 
:❑ 
:❑ 
:❑ 
'''Contraindications''' 
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
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{{familytree | | | | | | | | N01 | |N01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | O01 | |O01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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[[Category:Medicine]]
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[[Category:Resident survival guide]]
[[Category:Signs and symptoms]]
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</div>

Heart failure resident survival guide

2014-05-07T16:48:39Z

Ayokunle Olubaniyi: /* Treatment */

<div style="width: 80%;">
__NOTOC__
'''For acute heart failure prevention click [[Acute heart failure prevention|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
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{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
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{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
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{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
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{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree/end}}

==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

{{familytree/start}}
{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
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{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
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{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
{{familytree | | | | | | |,|-|^|-|.| | | | | |}}
{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
{{familytree/end}}

==Treatment==
The treatment of acute heart failure is largely dependent on whether the patient has a preserved [[ejection fraction]] ([[diastolic heart failure]]) or reduced [[ejection fraction]] ([[systolic heart failure]])

{{familytree/start}}
{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
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{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
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{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
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{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | | | | | | | | J01 | | |J01='''Classify the patient based on the left ventricular ejection fraction'''}}
{{familytree | | | | | | |,|-|^|-|.| | |}}
{{familytree | | | | | | K01 | | K02 | |K01=Diastolic heart failure|K02=Systolic heart failure}}
{{familytree | | | | | | |!| | | |!| | |}}
{{familytree | | | | | | X01 | | X02 | |X01=|X02=}}
{{familytree | | | | | | |`|-|v|-|'| | | |}}
{{familytree | | | | | | | | L01 | |L01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | M01 | |M01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[cardiac transplantation]]''' 
----
❑ 
:❑ 
:❑ 
:❑ 
'''Contraindications''' 
❑ 
❑ 
❑ 
❑ 
❑ </div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | N01 | |N01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | O01 | |O01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

[[Category:Disease]]
[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Primary care]]
[[Category:Resident survival guide]]
[[Category:Signs and symptoms]]
[[Category:Cardiology]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date cardiology]]
[[Category:Intensive care medicine]]

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Sandbox/22

2014-05-07T16:43:45Z

Ayokunle Olubaniyi: /* Hypertension */

{| class="wikitable sortable"
! Drug Class
! Drug
! Initial daily dose, target dose (mg)
|-
| [[Thiazide diuretics]] || [[Chlorthalidone]] || 12.5, 12.5-25
|-
| || [[Hydrochlorothiazide]] || 12.5-25, 25-100
|-
| || [[Bendroflumethiazide]] || 5, 10
|-
| || [[Indapamide]] || 1.25, 1.25-2.5
|-
| [[ACE inhibitors]] || [[Enalapril]] || 5, 20
|-
| || [[Lisinopril]] || 10, 40
|-
| || [[Captopril]] || 50, 150-200
|-
| [[ARBs]] || [[Candesartan]] || 4, 12-32
|-
| || [[Losartan]] || 50, 100
|-
| || [[Valsartan]] || 40-80, 160-320
|-
| || [[Eprosartan]] || 400, 600-800
|-
| || [[Irbesartan]] || 75, 300
|-
| [[Beta blockers]] || [[Atenolol]] || 25-50, 100
|-
| || [[Metoprolol succinate]] || 50, 100-200
|-
| [[Calcium channel blockers]]|| [[Amlodipine]] || 2.5, 10
|-
| || [[Diltiazem extended release]] || 120-180, 360
|-
| || [[Nitrendipine]] || 10, 20
|}

==Hypertension==
{{familytree/start}}
{{familytree | |,|-|-|-|v|-|-|^|-|-|v|-|-|-|.| | |}}
{{familytree | J01 | | J02 | | | | J03 |~| J04 | | |J01=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Dry''' 
----
❑ Consider outpatient treatment ❑ Dietary sodium restriction (2-3 g daily) ❑ [[Smoking cessation]] ❑ [[Alcohol]] abstinence (≤2 standard drinks per day for men; ≤1 for women) ❑ Encourage exercise/physical activity 
'''Although [[ACE inhibitors]] and [[beta blockers]] should not be administered to patients with [[acute decompensated heart failure]], if the patient is compensated in the outpatient setting then administer: ❑ [[ACE inhibitors]] or ([[ARBs]]) if LVEF is ≤ 40% ❑ [[Beta blockers]]'''<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> </div>|

J02=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Wet''' 
----
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] 
❑ Treat co-morbidities [[HTN]], [[DM]], [[CAD]], [[AF]]</div>|

J03=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Wet''' 
----
❑ CCU admission 
❑ Invasive hemodynamic monitoring (arterial line, consider pulmonary catheter if volume status unclear) 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) ❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] while monitoring [[blood pressure]] ❑ IV vasodilators</div>|J04=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Dry''' 
----
❑ CCU admission 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) 
❑ '''Persistent organ hypoperfusion''' (e.g., low urine output or persistent low SBP<85) 
:❑ [[Norepinephrine]] 0.2–1.0 mcg/kg/min, titrate to maintain a blood pressure of </div>}}
{{familytree | | | | | |!| | | | | |!| | | |!| | | | |}}
{{familytree | | | | | |`|-|-|v|-|-|^|-|-|-|'| | |}}
{{familytree | | | | | | | | X01 | | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | K01 | | | |K01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | | | | | |}}
{{familytree | | | | | | | | L01 | | | |L01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

==Underlying Anatomic Abnormalities Causing Heart Failure==
Heart failure may result from an abnormality of any one of the anatomical structures of the heart:
*Disorders of the [[great vessels]] (e.g. [[pulmonary hypertension]])
*[[Endocardium]]
*[[Myocardium]]
*[[Pericardium]]
*[[Valvular heart disease]] or

==Systolic versus Diastolic Heart Failure==
Patients may be broadly classified as having heart failure with depressed contractility or depressed relaxation
===Systolic Dysfunction===
The [[left ventricular ejection fraction]] is reduced in [[systolic dysfunction]] and there is depressed contractility of the heart.
===Disastolic Dysfunciton===
The [[left ventricular ejection fraction]] is preserved in [[diastolic dysfunction]] and there is an abnormality in myocardial relaxation or excessive myocardial stiffness. Systolic and diastolic dysfunction commonly occur in conjunction with each other.

==Left, Right and Biventricular Failure==
Another common method of classifying heart failure is based upon the ventricle involved (left sided versus right sided).
===Left Heart Failure===
*There is impaired left ventricular function with reduced flow into the aorta.
===Right Heart Failure===
*There is impaired right ventricular function with reduced flow into the pulmonary artery and lungs.
===Biventricular Failure===
*The most common cause of right heart failure is left heart failure, and mixed presentations are common, especially when the cardiac septum is involved.

==High Output Versus Low Output Failure==
===Low Output Failure===
*The [[cardiac output]] is reduced, and the [[systemic vascular resistance]] ([[SVR]]) is high. In low output failure, there is an inadequate supply of blood flow to meet normal metabolic demands.

===High Output Failure===
*The [[cardiac output]] is increased, and the [[systemic vascular resistance]] ([[SVR]]) is low. Rather than an inadequate supply of blood flow to meet normal metabolic demands as occurs in low output failure, in high output failure there is an excess requirement for oxygen and nutrients and the demand outstrips what the heart can provide.<ref>{{DorlandsDict|nine/000953450|high-output heart failure}}</ref> Causes of high output heart failure include severe [[anemia]], Gram negative [[septicaemia]], [[beriberi]] (vitamin B1/thiamine deficiency), [[thyrotoxicosis]], [[Paget's disease of bone|Paget's disease]], [[arteriovenous fistula]]e, or [[arteriovenous malformation]]s.

==Causes of Acute or Decompensated Heart Failure==
Chronic stable heart failure may easily decompensate. This most commonly results from an intercurrent illness (such as [[pneumonia]]), [[myocardial infarction]] (a heart attack), [[cardiac arrhythmia|arrhythmias]], uncontrolled [[hypertension]], or a patient's failure to maintain a fluid restriction, diet, or medication.<ref name="OPTIMIZE-HF">{{cite journal |author=Fonarow GC, Abraham WT, Albert NM, ''et al.'' |title=Factors Identified as Precipitating Hospital Admissions for Heart Failure and Clinical Outcomes: Findings From OPTIMIZE-HF |journal=Arch. Intern. Med. |volume=168 |issue=8 |pages=847–854 |year=2008 |month=April |pmid=18443260 |doi=10.1001/archinte.168.8.847}}</ref> Other well recognized precipitating factors include [[anemia]] and [[hyperthyroidism]] which place additional strain on the heart muscle. Excessive fluid or salt intake, and medication that causes fluid retention such as [[Non-steroidal anti-inflammatory drug|NSAIDs]] and [[thiazolidinedione]]s, may also precipitate decompensation.<ref>{{cite journal |author=Nieminen MS, Böhm M, Cowie MR, ''et al.'' |title=Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the Task Force on Acute Heart Failure of the European Society of Cardiology |journal=Eur. Heart J. |volume=26 |issue=4 |pages=384–416 |year=2005 |month=February |pmid=15681577 |doi=10.1093/eurheartj/ehi044 |url=http://eurheartj.oxfordjournals.org/cgi/content/full/26/4/384}}</ref>

==Differential Diagnosis of the Underlying Causes of Chronic Heart Failure==
===Common Causes of Left Sided Heart Failure===
* [[Aortic Regurgitation|Aortic regurgitation]]
* [[Aortic Stenosis|Aortic stenosis]]
* [[Hypertension]]
* [[Mitral Regurgitation|Mitral regurgitation]]
* [[Myocardial ischemia]]

A 19 year study of 13,000 healthy adults in the United States (the [[National Health and Nutrition Examination Survey]] (NHANES I) found the following causes ranked by Population Attributable Risk score:<ref>{{cite journal |author=He J; Ogden LG; Bazzano LA; Vupputuri S, ''et al.'' |title=Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study|journal=Arch. Intern. Med. |volume=161 |issue=7 |pages=996–1002|year=2001 |pmid= 11295963 |doi=10.1001/archinte.161.7.996 }}</ref>
#[[Ischaemic heart disease]] 62%
#[[Tobacco smoking|Cigarette smoking]] 16%
#[[Hypertension]] (high blood pressure)10%
#[[Obesity]] 8%
#[[Diabetes]] 3%
#[[Valvular heart disease]] 2% (much higher in older populations)

===Cardiomyopathies and Inflammatory Diseases===

=====[[Restrictive Cardiomyopathies]]=====
*[[Alcohol-Induced cardiomyopathy]]
*[[Amyloidosis]]
*[[Anthracycline induced cardiomyopathy]]
*[[Anthracyclines]]
*[[Arrhythmogenic right ventricular dysplasia]]
*[[Becker's muscular dystrophy]]
*[[Cardiac transplant]]
*[[Cocaine related cardiomyopathy]]
*[[Diabetic cardiomyopathy]]
*[[Endocardial fibrosis]]
*[[Eosinophilic heart disease]]
*[[Hemochromatosis]]
*Primary (idiopathic)
*[[Kearns-Sayre syndrome]]
*[[Radiation therapy]]
*[[Sarcoidosis]]
*Storage diseases
*[[Tumor]] infiltration

=====[[Dilated Cardiomyopathies]]=====
*[[Duchenne muscular dystrophy]]
*[[Chagas' disease]]
*[[Limb-girdle muscular dystrophy]]
*[[Mitochondrial myopathy]]
*[[Peripartum cardiomyopathy]]
*[[Trastuzumab]] [[Herceptin-lnduced Cardiomyopathy]]

=====Inflammatory Cardiomyopathies=====

*[[Bacterial Myocarditis]]
*[[Fungal myocarditis]]
*[[Giant Cell Myocarditis]]
*[[Myocarditis|Protozoal Myocarditis]]: [[Trypanosomiasis]] ([[Chagas Disease]])
*[[Rickettsial Myocarditis]]
*[[Sarcoidosis]]
*[[Spirochetal Infections]]
*[[Viral Myocarditis]]

===Congestive Heart Failure as a Consequence of Valvular Heart Disease===
*[[Acute aortic regurgitation]]
*[[Acute mitral regurgitation]]
*[[Aortic stenosis with Left Ventricular Systolic Dysfunction]]
*[[Chronic aortic regurgitation]]
*[[Chronic mitral regurgitation]]
*[[Mitral Stenosis]]

===Congestive Hert Failure Secondary to Congenital Heart Disease===

'''A. Causes of Congestive Heart Failure in Adults with Unoperated Congenital Heart Diseases'''
*[[Arrhythmia]]
*[[Atrial septal defect]] with [[mitral regurgitation]]] secondary to myxomatous mitral valve
*[[Congenital mitral regurgitation]]
*[[Drug abuse]], [[alcohol abuse]]
*[[Eisenmenger's syndrome]]
*[[Endocarditis]]
*Fibrocalcific degeneration of abnormal [[aortic valve]]
*[[Pregnancy]]
*Systemic ventricular dysfunction and/or [[tricuspid regurgitation]] in congenitally corrected transposition of the great arteries
*Other degenerative diseases ([[coronary artery disease]], [[hypertension]])
'''B. Causes of Congestive Heart Failure in Adults with Operated Congenital Heart Diseases'''
*[[Arrhythmia]]
*[[Endocarditis]]
*Myocardial dysfunction
*Persistent left-to-right shunt
*Prosthetic valve dysfunction
*Pulmonary vascular disease
*Status post [[Fontan operation]]
*Valvular regurgitation
*Other degenerative diseases ([[coronary artery disease]], [[hypertension]])

=== Right Ventricular Failure ===
Factors affected right ventricle and to be eliminated during management of congestive heart failure.
A. Right ventricular myocardial dysfunction
#[[Right ventricular myocardial infarction]]
#[[Dilated cardiomyopathy]]
#[[Arrhythmogenic right ventricular dysplasia|Right ventricular dysplasia]]
B. Primary right ventricular pressure overload
#[[Left ventricular failure]]
#[[Mitral valve]] disease
#[[Atrial myxoma]]
#[[Pulmonary veno-occlusive disease]]
#[[Cor pulmonale]]
#:*[[Chronic obstructive pulmonary disease]]
#:*[[Primary pulmonary hypertension]]
#:*[[Pulmonary embolism]]
#[[Pulmonic stenosis]]
#:*[[Supravalvular pulmonic stenosis]]
#:*[[Valvular pulmonic stenosis]]
#:*[[Subvalvular pulmonic stenosis]]
#[[Ventricular septal defect]]
#Aortopulmonary communication
C. Primary right ventricular volume overload
#[[Pulmonic regurgitation]]
#[[Tricuspid regurgitation]]
#[[Atrial septal defect]]
#[[Partial anomalous pulmonary venous return]]
D. Impediment to right ventricular inflow
#[[Tricuspid stenosis]]
#[[Cardiac tamponade]]
#[[pericarditis |Constrictive pericarditis]]
#[[cardiomyopathy|Restrictive cardiomyopathy]]

== Differential Diagnosis of Causes of Heart Failure Segregated by Left and Right Sided Heart Failure==
===Left Ventricular Failure===
====Most Common Causes:====
* [[Aortic Regurgitation|Aortic regurgitation]]
* [[Aortic Stenosis|Aortic stenosis]]
* [[Hypertension]]
* [[Mitral Regurgitation|Mitral regurgitation]]
* [[Myocardial ischemia]]

====Expanded List of Causes:====
* [[Atrial fibrillation]]
* [[Alcoholism]]
* [[Anemia]]
* [[Angina]]
* [[Aortic Regurgitation|Aortic regurgitation]]
* [[Aortic Stenosis]]
* [[Arteriovenous fistula]]
* [[Beriberi]]
* [[aneurysm|Cardiac aneurysm]]
* [[Cardiomyopathy]]
* [[pericarditis|Constrictive pericarditis]]
* [[Drugs]], [[toxin]]s
* [[Hypertension]]
* [[Hyperthyroidism]]
* [[Hypovolemia]]
* [[Hypoxia]]
* Mediastinal tumors
* [[Mitral Regurgitation]]
* [[Myocardial Infarction]]
* [[Paget's Disease]]
* [[Pancoast's Tumor]]
* [[Pericardial effusion]]
* [[Pericardial tamponade]]
* [[Perimyocarditis]]
* [[Protein deficiency]]
* [[Restrictive cardiomyopathy]]
* [[Papillary muscle rupture|Rupture of the papillary muscles]]
* [[Sepsis]]
* [[Superior Vena Cava]] thrombosis

===Right Ventricular Failure ===
====Most Common Causes:====
* [[Cardiomyopathy]]
* [[Cor pulmonale]]
* [[myocarditis|Diffuse myocarditis]]
* Left heart failure

====Other Causes:====
* After [[left ventricular failure]]
* After pulmonary resection
* [[Alveolitis|Allergic alveolitis]]
* [[asthma|Bronchial asthma]]
* [[bronchitis|Chronic bronchitis]]
* [[Alveolitis|Honeycomb lung]]
* [[Hyperglobulia]]
* [[Emphysema]]
* [[Mitral Stenosis]]
* [[Right ventricular myocardial infarction]]
* [[Pickwickian Syndrome]]
* Pleural fibrosis
* [[Pneumoconiosis]]
* [[Pulmonary fibrosis]]
* [[Pulmonic regurgitation]]
* [[Pulmonic stenosis]]
* [[Sarcoidosis]]
* [[pulmonary emboli|Severe relapsing pulmonary emboli]]
* [[Silicosis]]
* [[Tachycardia]]
* [[Tricuspid insufficiency]]

===Others===
* [[Ascorbic acid deficiency]]
* [[Cardiac amyloidosis]]
* [[Carnitine deficiency]]
* Cervical vein stasis of non-cardiac genesis
* [[Congenital heart disease]]
* [[Cyanosis]] of non-cardiac genesis
* [[Diabetes Mellitus]]
* [[Ddx:Dyspnea|Dyspnea]] of non-cardiac genesis
* [[Edema]] of non-cardiac genesis
* [[Hemochromatosis]]
* [[Pleural effusion]] of non-cardiac genesis
* [[Pulmonary edema]] of non-cardiac genesis
* [[Thiamine deficiency]]
* [[Thyroid disease]]

Heart failure resident survival guide

2014-05-07T15:52:02Z

Ayokunle Olubaniyi: /* Treatment */

<div style="width: 80%;">
__NOTOC__
'''For acute heart failure prevention click [[Acute heart failure prevention|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
{{familytree | | | |!| |}}
{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
{{familytree | |!| | | |!| | |}}
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
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{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
{{familytree | | | |!| | | |!| | | |}}
{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree/end}}

==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

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{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
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{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
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{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
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{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
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{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
{{familytree | | | | | | |,|-|^|-|.| | | | | |}}
{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
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==Treatment==
The treatment of acute heart failure is largely dependent on whether the patient has a preserved [[ejection fraction]] ([[diastolic heart failure]]) or reduced [[ejection fraction]] ([[systolic heart failure]])

====Diastolic Heart Failure (LVEF ≥ 50%)====

====Systolic Heart Failure (LVEF ≤ 40%)====
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{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
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{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
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{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
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{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | |,|-|-|-|v|-|-|^|-|-|v|-|-|-|.| | |}}
{{familytree | J01 | | J02 | | | | J03 |~| J04 | | |J01=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Dry''' 
----
❑ Consider outpatient treatment ❑ Dietary sodium restriction (2-3 g daily) ❑ [[Smoking cessation]] ❑ [[Alcohol]] abstinence (≤2 standard drinks per day for men; ≤1 for women) ❑ Encourage exercise/physical activity 
'''Although [[ACE inhibitors]] and [[beta blockers]] should not be administered to patients with [[acute decompensated heart failure]], if the patient is compensated in the outpatient setting then administer: ❑ [[ACE inhibitors]] or ([[ARBs]]) if LVEF is ≤ 40% ❑ [[Beta blockers]]'''<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> </div>|

J02=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Wet''' 
----
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] 
❑ Treat co-morbidities [[HTN]], [[DM]], [[CAD]], [[AF]]</div>|

J03=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Wet''' 
----
❑ CCU admission 
❑ Invasive hemodynamic monitoring (arterial line, consider pulmonary catheter if volume status unclear) 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) ❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] while monitoring [[blood pressure]] ❑ IV vasodilators</div>|J04=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Dry''' 
----
❑ CCU admission 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) 
❑ '''Persistent organ hypoperfusion''' (e.g., low urine output or persistent low SBP<85) 
:❑ [[Norepinephrine]] 0.2–1.0 mcg/kg/min, titrate to maintain a blood pressure of </div>}}
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{{familytree | | | | | |`|-|-|v|-|-|^|-|-|-|'| | |}}
{{familytree | | | | | | | | X01 | | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
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{{familytree | | | | | | | | K01 | | | |K01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | | | | | |}}
{{familytree | | | | | | | | L01 | | | |L01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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[[Category:Resident survival guide]]
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</div>

Heart failure resident survival guide

2014-05-07T15:06:51Z

Ayokunle Olubaniyi:

<div style="width: 80%;">
__NOTOC__
'''For acute heart failure prevention click [[Acute heart failure prevention|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
{{familytree | | | |!| |}}
{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
{{familytree | |!| | | |!| | |}}
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
{{familytree | | | |!| | | |!| | | |}}
{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree/end}}

==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

{{familytree/start}}
{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
{{familytree | | | | | | | | |!| | | | | |}}
{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
{{familytree | | | | | | |,|-|^|-|.| | | | | |}}
{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
{{familytree/end}}

==Treatment==
{{familytree/start}}
{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
{{familytree | | | | | | | | |!| | | |}}
{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
{{familytree | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | |,|-|-|-|v|-|-|^|-|-|v|-|-|-|.| | |}}
{{familytree | J01 | | J02 | | | | J03 |~| J04 | | |J01=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Dry''' 
----
❑ Consider outpatient treatment ❑ Dietary sodium restriction (2-3 g daily) ❑ [[Smoking cessation]] ❑ [[Alcohol]] abstinence (≤2 standard drinks per day for men; ≤1 for women) ❑ Encourage exercise/physical activity 
'''Although [[ACE inhibitors]] and [[beta blockers]] should not be administered to patients with [[acute decompensated heart failure]], if the patient is compensated in the outpatient setting then administer: ❑ [[ACE inhibitors]] or ([[ARBs]]) if LVEF is ≤ 40% ❑ [[Beta blockers]]'''<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> </div>|

J02=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Wet''' 
----
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] 
❑ Treat co-morbidities [[HTN]], [[DM]], [[CAD]], [[AF]]</div>|

J03=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Wet''' 
----
❑ CCU admission 
❑ Invasive hemodynamic monitoring (arterial line, consider pulmonary catheter if volume status unclear) 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) ❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] while monitoring [[blood pressure]] ❑ IV vasodilators</div>|J04=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Dry''' 
----
❑ CCU admission 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) 
❑ '''Persistent organ hypoperfusion''' (e.g., low urine output or persistent low SBP<85) 
:❑ [[Norepinephrine]] 0.2–1.0 mcg/kg/min, titrate to maintain a blood pressure of </div>}}
{{familytree | | | | | |!| | | | | |!| | | |!| | | | |}}
{{familytree | | | | | |`|-|-|v|-|-|^|-|-|-|'| | |}}
{{familytree | | | | | | | | X01 | | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | K01 | | | |K01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | | | | | |}}
{{familytree | | | | | | | | L01 | | | |L01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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Acute heart failure prevention

2014-05-07T15:05:23Z

Ayokunle Olubaniyi: Created page with "Click here for acute heart failure primary prevention Chronic heart failure resident survival guide|Click here fo..."

[[Acute heart failure prevention resident survival guide|Click here for acute heart failure primary prevention]]

[[Chronic heart failure resident survival guide|Click here for acute heart failure secondary prevention]]

Heart failure resident survival guide

2014-05-06T21:29:23Z

Ayokunle Olubaniyi:

<div style="width: 80%;">
__NOTOC__
'''For acute heart failure prevention resident survival guide click [[Acute heart failure prevention resident survival guide|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
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! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
{{familytree | | | |!| |}}
{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
{{familytree | |!| | | |!| | |}}
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
{{familytree | | | |!| | | |!| | | |}}
{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree/end}}

==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

{{familytree/start}}
{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
{{familytree | | | | | | | | |!| | | | | |}}
{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
{{familytree | | | | | | |,|-|^|-|.| | | | | |}}
{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
{{familytree/end}}

==Treatment==
{{familytree/start}}
{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
{{familytree | | | | | | | | |!| | | |}}
{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
{{familytree | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | |,|-|-|-|v|-|-|^|-|-|v|-|-|-|.| | |}}
{{familytree | J01 | | J02 | | | | J03 |~| J04 | | |J01=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Dry''' 
----
❑ Consider outpatient treatment ❑ Dietary sodium restriction (2-3 g daily) ❑ [[Smoking cessation]] ❑ [[Alcohol]] abstinence (≤2 standard drinks per day for men; ≤1 for women) ❑ Encourage exercise/physical activity 
'''Although [[ACE inhibitors]] and [[beta blockers]] should not be administered to patients with [[acute decompensated heart failure]], if the patient is compensated in the outpatient setting then administer: ❑ [[ACE inhibitors]] or ([[ARBs]]) if LVEF is ≤ 40% ❑ [[Beta blockers]]'''<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> </div>|

J02=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Wet''' 
----
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] 
❑ Treat co-morbidities [[HTN]], [[DM]], [[CAD]], [[AF]]</div>|

J03=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Wet''' 
----
❑ CCU admission 
❑ Invasive hemodynamic monitoring (arterial line, consider pulmonary catheter if volume status unclear) 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) ❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] while monitoring [[blood pressure]] ❑ IV vasodilators</div>|J04=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Dry''' 
----
❑ CCU admission 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) 
❑ '''Persistent organ hypoperfusion''' (e.g., low urine output or persistent low SBP<85) 
:❑ [[Norepinephrine]] 0.2–1.0 mcg/kg/min, titrate to maintain a blood pressure of </div>}}
{{familytree | | | | | |!| | | | | |!| | | |!| | | | |}}
{{familytree | | | | | |`|-|-|v|-|-|^|-|-|-|'| | |}}
{{familytree | | | | | | | | X01 | | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | K01 | | | |K01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | | | | | |}}
{{familytree | | | | | | | | L01 | | | |L01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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[[Category:Medicine]]
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[[Category:Resident survival guide]]
[[Category:Signs and symptoms]]
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[[Category:Intensive care medicine]]

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</div>

Heart failure resident survival guide

2014-05-06T21:27:26Z

Ayokunle Olubaniyi:

<div style="width: 80%;">
__NOTOC__
'''For acute heart failure prevention resident survival guide click [[Acute heart failure prevention resident survival guide|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
{{familytree | | | |!| |}}
{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
{{familytree | |!| | | |!| | |}}
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
{{familytree | | | |!| | | |!| | | |}}
{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree/end}}

==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

{{familytree/start}}
{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
{{familytree | | | | | | | | |!| | | | | |}}
{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
{{familytree | | | | | | |,|-|^|-|.| | | | | |}}
{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
{{familytree/end}}

==Treatment==
{{familytree/start}}
{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
{{familytree | | | | | | | | |!| | | |}}
{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
{{familytree | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | |,|-|-|-|v|-|-|^|-|-|v|-|-|-|.| | |}}
{{familytree | J01 | | J02 | | | | J03 |~| J04 | | |J01=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Dry''' 
----
❑ Consider outpatient treatment ❑ Dietary sodium restriction (2-3 g daily) ❑ [[Smoking cessation]] ❑ [[Alcohol]] abstinence (≤2 standard drinks per day for men; ≤1 for women) ❑ Encourage exercise/physical activity 
'''Although [[ACE inhibitors]] and [[beta blockers]] should not be administered to patients with [[acute decompensated heart failure]], if the patient is compensated in the outpatient setting then administer: ❑ [[ACE inhibitors]] or ([[ARBs]]) if LVEF is ≤ 40% ❑ [[Beta blockers]]'''<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> </div>|

J02=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Wet''' 
----
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] 
❑ Treat co-morbidities [[HTN]], [[DM]], [[CAD]], [[AF]]</div>|

J03=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Wet''' 
----
❑ CCU admission 
❑ Invasive hemodynamic monitoring (arterial line, consider pulmonary catheter if volume status unclear) 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) ❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] while monitoring [[blood pressure]] ❑ IV vasodilators</div>|J04=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Dry''' 
----
❑ CCU admission 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) 
❑ '''Persistent organ hypoperfusion''' (e.g., low urine output or persistent low SBP<85) 
:❑ [[Norepinephrine]] 0.2–1.0 mcg/kg/min, titrate to maintain a blood pressure of </div>}}
{{familytree | | | | | |!| | | | | |!| | | |!| | | | |}}
{{familytree | | | | | |`|-|-|v|-|-|^|-|-|-|'| | |}}
{{familytree | | | | | | | | X01 | | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | K01 | | | |K01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | | | | | |}}
{{familytree | | | | | | | | L01 | | | |L01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

[[Category:Disease]]
[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Primary care]]
[[Category:Resident survival guide]]
[[Category:Signs and symptoms]]
[[Category:Cardiology]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date cardiology]]
[[Category:Intensive care medicine]]

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</div>

Acute heart failure prevention resident survival guide

2014-05-06T21:24:35Z

Ayokunle Olubaniyi: /* Prevention */

__NOTOC__
{{CMG}}; {{AE}} {{MS}}; {{AO}}

==Overview==

==Prevention==
{{familytree/start}}
{{familytree | | | | | A00 | | A00=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have stage A or stage B of heart failure according to the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]]?'''</div>}}
{{familytree | |,|-|-|-|+|-|-|-|.| | | | }}
{{familytree | Z01 | | Z02 | | Z03 | |Z01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage A]]''' 
❑ '''At high risk for heart failure''' 
:❑ Patients with [[HTN]], [[DM]], [[obesity]], [[CAD]], [[metabolic syndrome]] 
:❑ Family history of [[cardiomyopathy]] 
:❑ Patients using cardiotoxins

 '''AND''' 
❑ '''No structural heart disease'''

 '''AND''' 
❑ '''No symptom of heart failure''' </div>|Z02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage B]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''No signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>|Z03=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Neither stage A nor stage B'''</div>}}
{{familytree | |!| | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | A01 | | A02 | | A03 | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Yes, the patient has stage A'''
----
Therapeutic goals: 
❑ Promote healthy lifestyle 
❑ Prevent CAD and comorbidities 
❑ Prevent LV structural abnormalities</div>|A02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Yes, the patient has stage B'''
----
Therapeutic goal:
❑ Prevent symptoms of heart failure</div>
|A03=<div style="float: left; text-align: left; width: 20em; padding:1em;">No preventive therapy is needed</div>
}}
{{familytree | |!| | | |!| |}}
{{familytree | B01 | | B02 | | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ Control HTN and lipid disorders 
:❑ [[ACE inhibitors]] or ([[ARBs]]) in patients with vascular disease or DM 
:❑ [[Statins]] 
❑ Minimize risk factors
:❑ Dietary sodium restriction (2-3 g daily) 
:❑ [[Smoking cessation]] 
:❑ Alcohol abstinence (≤2 standard drinks per day for men; ≤1 for women) 
:❑ Encourage exercise/physical activity</div>|B02=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ Administer [[ACE inhibitors]] or ([[ARBs]]) in patients with: 
:❑ Prior [[MI]] and LVEF ≤40% to prevent heart failure ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) '''OR'''
:❑ LVEF ≤40% ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
❑ Administer [[beta blockers]] in patients with: 
:❑ Prior [[MI]] and LVEF ≤ 40% to prevent heart failure ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ LVEF ≤ 40% to prevent heart failure ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
❑ [[Statins]] 
:❑ Patients with MI ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
❑ Implantable cardioverter defibrillator (ICD) to prevent sudden death in: 
:❑ Asymptomatic ischemic cardiomyopathy ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence B]]) 
::❑ ≥ 40 day post-[[MI]] 
::❑ LVEF ≤ 30% 
::❑ On GDMT 
❑ The use of CCBs e.g., verapamil and diltiazem in patients with LVEF ≤ 30%</div>}}
{{familytree/end}}

==References==
{{Reflist|2}}

[[Category:Disease]]
[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Primary care]]
[[Category:Resident survival guide]]
[[Category:Signs and symptoms]]
[[Category:Cardiology]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date cardiology]]
[[Category:Intensive care medicine]]

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{{WikiDoc Sources}}

Heart failure resident survival guide

2014-05-06T21:09:24Z

Ayokunle Olubaniyi: /* Primary Prevention */

<div style="width: 80%;">
__NOTOC__
'''For acute heart failure prevention resident survival guide click [[Acute heart failure prevention resident survival guide|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Prevention
:[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage A & B]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
{{familytree | | | |!| |}}
{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
{{familytree | |!| | | |!| | |}}
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
{{familytree | | | |!| | | |!| | | |}}
{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
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==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

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{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
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{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
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{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
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{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
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{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
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{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
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==Treatment==
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{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
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{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
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{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
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{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
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{{familytree | J01 | | J02 | | | | J03 |~| J04 | | |J01=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Dry''' 
----
❑ Consider outpatient treatment ❑ Dietary sodium restriction (2-3 g daily) ❑ [[Smoking cessation]] ❑ [[Alcohol]] abstinence (≤2 standard drinks per day for men; ≤1 for women) ❑ Encourage exercise/physical activity 
'''Although [[ACE inhibitors]] and [[beta blockers]] should not be administered to patients with [[acute decompensated heart failure]], if the patient is compensated in the outpatient setting then administer: ❑ [[ACE inhibitors]] or ([[ARBs]]) if LVEF is ≤ 40% ❑ [[Beta blockers]]'''<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> </div>|

J02=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Wet''' 
----
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] 
❑ Treat co-morbidities [[HTN]], [[DM]], [[CAD]], [[AF]]</div>|

J03=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Wet''' 
----
❑ CCU admission 
❑ Invasive hemodynamic monitoring (arterial line, consider pulmonary catheter if volume status unclear) 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) ❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] while monitoring [[blood pressure]] ❑ IV vasodilators</div>|J04=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Dry''' 
----
❑ CCU admission 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) 
❑ '''Persistent organ hypoperfusion''' (e.g., low urine output or persistent low SBP<85) 
:❑ [[Norepinephrine]] 0.2–1.0 mcg/kg/min, titrate to maintain a blood pressure of </div>}}
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{{familytree | | | | | | | | X01 | | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
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{{familytree | | | | | | | | K01 | | | |K01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
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{{familytree | | | | | | | | L01 | | | |L01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

[[Category:Disease]]
[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Primary care]]
[[Category:Resident survival guide]]
[[Category:Signs and symptoms]]
[[Category:Cardiology]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date cardiology]]
[[Category:Intensive care medicine]]

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</div>

Acute heart failure prevention resident survival guide

2014-05-06T21:09:03Z

Ayokunle Olubaniyi: Created page with "__NOTOC__ {{CMG}}; {{AE}} {{MS}}; {{AO}} ==Overview== ==Prevention== {{familytree/start}} {{familytree | | | | | A00 | | A00=<div style="float: left; text-align: left; width..."

__NOTOC__
{{CMG}}; {{AE}} {{MS}}; {{AO}}

==Overview==

==Prevention==
{{familytree/start}}
{{familytree | | | | | A00 | | A00=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have stage A or stage B of heart failure according to the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]]?'''</div>}}
{{familytree | |,|-|-|-|+|-|-|-|.| | | | }}
{{familytree | A01 | | A02 | | A03 | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Yes, the patient has stage A'''
----
Therapeutic goals: 
❑ Promote healthy lifestyle 
❑ Prevent CAD and comorbidities 
❑ Prevent LV structural abnormalities</div>|A02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Yes, the patient has stage B'''
----
Therapeutic goal:
❑ Prevent symptoms of heart failure</div>
|A03=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''No, the patient does not belong to any of the stages'''
----
No preventive therapy is needed</div>}}
{{familytree | |!| | | |!| |}}
{{familytree | B01 | | B02 | | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ Control HTN and lipid disorders 
:❑ [[ACE inhibitors]] or ([[ARBs]]) in patients with vascular disease or DM 
:❑ [[Statins]] 
❑ Minimize risk factors
:❑ Dietary sodium restriction (2-3 g daily) 
:❑ [[Smoking cessation]] 
:❑ Alcohol abstinence (≤2 standard drinks per day for men; ≤1 for women) 
:❑ Encourage exercise/physical activity</div>|B02=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ Administer [[ACE inhibitors]] or ([[ARBs]]) in patients with: 
:❑ Prior [[MI]] and LVEF ≤40% to prevent heart failure ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) '''OR'''
:❑ LVEF ≤40% ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
❑ Administer [[beta blockers]] in patients with: 
:❑ Prior [[MI]] and LVEF ≤ 40% to prevent heart failure ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ LVEF ≤ 40% to prevent heart failure ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
❑ [[Statins]] 
:❑ Patients with MI ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
❑ Implantable cardioverter defibrillator (ICD) to prevent sudden death in: 
:❑ Asymptomatic ischemic cardiomyopathy ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence B]]) 
::❑ ≥ 40 day post-[[MI]] 
::❑ LVEF ≤ 30% 
::❑ On GDMT 
❑ The use of CCBs e.g., verapamil and diltiazem in patients with LVEF ≤ 30%</div>}}
{{familytree/end}}

==References==
{{Reflist|2}}

[[Category:Disease]]
[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Primary care]]
[[Category:Resident survival guide]]
[[Category:Signs and symptoms]]
[[Category:Cardiology]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date cardiology]]
[[Category:Intensive care medicine]]

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Heart failure resident survival guide

2014-05-06T21:05:50Z

Ayokunle Olubaniyi:

<div style="width: 80%;">
__NOTOC__
'''For acute heart failure prevention resident survival guide click [[Acute heart failure prevention resident survival guide|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Prevention
:[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage A & B]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
{{familytree | | | |!| |}}
{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
{{familytree | |!| | | |!| | |}}
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
{{familytree | | | |!| | | |!| | | |}}
{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree/end}}

==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

{{familytree/start}}
{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
{{familytree | | | | | | | | |!| | | | | |}}
{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
{{familytree | | | | | | |,|-|^|-|.| | | | | |}}
{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
{{familytree/end}}

==Treatment==
{{familytree/start}}
{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
{{familytree | | | | | | | | |!| | | |}}
{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
{{familytree | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | |,|-|-|-|v|-|-|^|-|-|v|-|-|-|.| | |}}
{{familytree | J01 | | J02 | | | | J03 |~| J04 | | |J01=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Dry''' 
----
❑ Consider outpatient treatment ❑ Dietary sodium restriction (2-3 g daily) ❑ [[Smoking cessation]] ❑ [[Alcohol]] abstinence (≤2 standard drinks per day for men; ≤1 for women) ❑ Encourage exercise/physical activity 
'''Although [[ACE inhibitors]] and [[beta blockers]] should not be administered to patients with [[acute decompensated heart failure]], if the patient is compensated in the outpatient setting then administer: ❑ [[ACE inhibitors]] or ([[ARBs]]) if LVEF is ≤ 40% ❑ [[Beta blockers]]'''<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> </div>|

J02=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Wet''' 
----
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] 
❑ Treat co-morbidities [[HTN]], [[DM]], [[CAD]], [[AF]]</div>|

J03=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Wet''' 
----
❑ CCU admission 
❑ Invasive hemodynamic monitoring (arterial line, consider pulmonary catheter if volume status unclear) 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) ❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] while monitoring [[blood pressure]] ❑ IV vasodilators</div>|J04=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Dry''' 
----
❑ CCU admission 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) 
❑ '''Persistent organ hypoperfusion''' (e.g., low urine output or persistent low SBP<85) 
:❑ [[Norepinephrine]] 0.2–1.0 mcg/kg/min, titrate to maintain a blood pressure of </div>}}
{{familytree | | | | | |!| | | | | |!| | | |!| | | | |}}
{{familytree | | | | | |`|-|-|v|-|-|^|-|-|-|'| | |}}
{{familytree | | | | | | | | X01 | | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | K01 | | | |K01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | | | | | |}}
{{familytree | | | | | | | | L01 | | | |L01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

==Primary Prevention==
{{familytree/start}}
{{familytree | | | | | A00 | | A00=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have stage A or stage B of heart failure according to the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]]?'''</div>}}
{{familytree | |,|-|-|-|+|-|-|-|.| | | | }}
{{familytree | A01 | | A02 | | A03 | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Yes, the patient has stage A'''
----
Therapeutic goals: 
❑ Promote healthy lifestyle 
❑ Prevent CAD and comorbidities 
❑ Prevent LV structural abnormalities</div>|A02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Yes, the patient has stage B'''
----
Therapeutic goal:
❑ Prevent symptoms of heart failure</div>
|A03=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''No, the patient does not belong to any of the stages'''
----
No preventive therapy is needed</div>}}
{{familytree | |!| | | |!| |}}
{{familytree | B01 | | B02 | | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ Control HTN and lipid disorders 
:❑ [[ACE inhibitors]] or ([[ARBs]]) in patients with vascular disease or DM 
:❑ [[Statins]] 
❑ Minimize risk factors
:❑ Dietary sodium restriction (2-3 g daily) 
:❑ [[Smoking cessation]] 
:❑ Alcohol abstinence (≤2 standard drinks per day for men; ≤1 for women) 
:❑ Encourage exercise/physical activity</div>|B02=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ Administer [[ACE inhibitors]] or ([[ARBs]]) in patients with: 
:❑ Prior [[MI]] and LVEF ≤40% to prevent heart failure ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) '''OR'''
:❑ LVEF ≤40% ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
❑ Administer [[beta blockers]] in patients with: 
:❑ Prior [[MI]] and LVEF ≤ 40% to prevent heart failure ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ LVEF ≤ 40% to prevent heart failure ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
❑ [[Statins]] 
:❑ Patients with MI ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
❑ Implantable cardioverter defibrillator (ICD) to prevent sudden death in: 
:❑ Asymptomatic ischemic cardiomyopathy ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence B]]) 
::❑ ≥ 40 day post-[[MI]] 
::❑ LVEF ≤ 30% 
::❑ On GDMT 
❑ The use of CCBs e.g., verapamil and diltiazem in patients with LVEF ≤ 30%</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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[[Category:Resident survival guide]]
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[[Category:Intensive care medicine]]

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</div>

Heart failure resident survival guide

2014-05-06T21:04:24Z

Ayokunle Olubaniyi:

<div style="width: 80%;">
__NOTOC__
'''For infective endocarditis prevention resident survival guide click [[Acute heart failure prevention resident survival guide|here]].'''

{{CMG}}; {{AE}} {{MS}}; {{AO}}

{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0";
|-
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Heart Failure Resident Survival Guide Microchapters}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Classification|Classification]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Treatment
:[[Acute heart failure resident survival guide#Treatment|Stage C]]
:[[Chronic heart failure resident survival guide|Stage D]]
:[[Acute heart failure resident survival guide#Diuretic Therapy|Diuretic Therapy]]
:[[Acute heart failure resident survival guide#Medications|Medications]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | Prevention
:[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage A & B]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute heart failure resident survival guide#Don'ts|Don'ts]]
|}

==Overview==
Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as [[acute decompensated heart failure]], [[flash pulmonary edema]], [[ADHF]]). ADHF presents with acute shortness of breath due to the development of [[pulmonary edema]] (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include [[hypotension]] with impaired and organ perfusion manifested by [[worsening renal function]], altered mentation and [[cold clammy extremities]]. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated [[congestive heart failure]] include [[oxygen]] to improve [[hypoxia]], [[diuresis]] to reduce both [[preload]] and intravascular volume and vasodilators to reduce [[afterload]]. Some of the mainstays of [[chronic heart failure]] therapy are not initiated acutely ([[ACE inhibitors]], [[beta blockers]] and [[digoxin]]).

==Classification==

===Based on the Severity of Congestive Heart Failure===
The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:
{|class="wikitable"
! NYHA classification!! Description
|-
| '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
|-
| '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
|-
| '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
|-
| '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
|}
''NYHA - New York Heart Association''

===Based on the Stage of Heart Failure===
{|class="wikitable"
! ACCF/AHA Stages !! Description
|-
| '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
|-
| '''B'''|| Structural heart disease but without signs or symptoms of HF
|-
| '''C'''|| Structural heart disease with prior or current symptoms of HF
|-
| '''D'''|| Refractory HF requiring specialized interventions
|}
''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''

===Based on Left Ventricular Ejection Fraction (LVEF)===
* [[Diastolic dysfunction|Heart failure with preserved ejection fraction]] (HFpEF) or [[diastolic heart failure]]: [[ejection fraction]] ≥ 50%
* [[Systolic dysfunction|Heart failure with reduced ejection fraction]] (HFrEF) or [[Systolic dysfunction|systolic heart failure]]: [[ejection fraction]] ≤ 40%

==Causes==
===Life Threatening Causes===
[[Congestive heart failure|Acute decompensated heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
===Common Causes===
* [[Acute coronary syndrome]]
* [[Acute kidney injury]]
* [[Myocarditis|Acute severe myocarditis]]
* [[Cardiac arrhythmias]]
* [[Cardiomyopathy]]
* [[Cardiotoxicity|Cardiotoxic agents]] - [[alcohol]], [[cocaine]]
* Decompensation of an underlying [[chronic heart failure]]
* [[Hypertensive emergency|Hypertensive crisis]]
* [[Pulmonary embolus]]
* [[Sepsis|Systemic Inflammatory response syndrome]]
* [[Valvular heart disease]]

Click '''[[Congestive heart failure causes|here]]''' for the complete list of causes.

==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 

Boxes in red signify that an urgent management is needed.

'''Abbreviations:'''
'''MAP:''' [[Mean arterial pressure]];
'''NYHA:''' New York Heart Association;
'''SBP:''' [[Systolic blood pressure]]

 
{{familytree/start}}
{{familytree | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Identify cardinal findings that increase the pretest probability of acute heart failure''' 
❑ Past medical history of [[heart failure]] 
❑ History of [[orthopnea]] and [[paroxysmal nocturnal dyspnea]] 
❑ [[Dyspnea]] 
❑ [[Chest pain]] 
❑ Pulmonary [[crepitations]]/[[rales]]/[[crackles]] 
❑ [[Cool extremities]] 
❑ [[Pedal edema|Peripheral edema]] 
❑ [[Heart sounds#Third heart sound S3|Third heart sound (S3)]]</div>}}
{{familytree | | | |!| |}}
{{familytree | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?''' 
❑ [[Hypotension]] ([[SBP]] < 90 mmHg or drop in [[MAP]] >30 mmHg) 
❑ [[Altered mental status]] 
❑ [[Cool extremities|Cold and clammy extremities]] 
❑ [[Oliguria|Urine output <0.5mL/kg/hr]] 
❑ [[Metabolic acidosis]] </div>}}
{{familytree | |,|-|^|-|.| |}}
{{familytree | B01 | | B02 | |B01=<div style=" background: #FA8072"> {{fontcolor|#F8F8FF|Yes}}</div> |B02='''No'''}}
{{familytree | |!| | | |!| | |}}
{{familytree | C01 | | C02 | |C01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Treat cardiogenic shock''' 
❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring 
❑ Initiate [[oxygen|oxygen]] therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref> 
:❑ Non-rebreather face masks 
:❑ [[Positive airway pressure|Continuous positive airway pressure (CPAP)]] or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks 
:❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails 
❑ For [[SBP|SBP ]] 85 - 100 mm Hg 
:❑ Consider [[dobutamine|dobutamine at 2.5 to 5 mcg/kg/min]] or [[milrinone|milrinone at 0.125 to 0.75 mcg/kg/min]] 
❑ For [[SBP|SBP ]] < 85 mm Hg 
:❑ Consider [[dopamine|dopamine at 5 to 10 mcg/kg/min]] and [[norepinephrine|norepinephrine at 0.2–1.0 mcg/kg/min]] 
❑ Consider [[Intra-aortic balloon pump|intra-aortic balloon pump]], if [[hypotension|hypotension]] persists 
❑ Consider [[Ventricular assist device|left ventricular assist devices in severe cases]] 
[[Cardiogenic shock resident survival guide|Click here for cardiogenic shock resident survival guide]]</div>|C02=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have severe symptoms of heart failure?''' 
❑ '''NYHA class III''' 
:❑ Marked limitation of physical activity 
:❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF 
❑ '''NYHA class IV''' 
:❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
</div> }}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01=<div style=" background: #FA8072; color: #F8F8FF;"> {{fontcolor|#F8F8FF|Yes}}</div> |D02='''No'''}}
{{familytree | | | |!| | | |!| | | |}}
{{familytree | | | E01 | | E02 |E01=<div style=" background: #FA8072; color: #F8F8FF;; text-align: left; width: 25em; padding:1em;">'''Urgent treatment''' 
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy (click for details)]] 
❑ Administer [[oxygen|oxygen (as noted above)]] 
❑ Administer IV [[Vasodilators|vasodilators]] e.g.,[[nitroglycerin|nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min]] '''OR''' [[nesiritide|nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute]] </div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''[[Acute heart failure resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree/end}}

==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref>

'''Abbreviations:'''
'''ARDS:''' [[Acute respiratory distress syndrome]];
'''BNP:''' [[B-type natriuretic peptide]];
'''BUN:''' [[Blood urea nitrogen]];
'''CAD:''' [[Coronary artery disease]];
'''CBC:''' [[Complete blood count]];
'''CCB:''' [[Calcium channel blocker]];
'''CT:''' [[Computed tomography]];
'''CXR:''' [[Chest X-ray]];
'''DM:''' [[Diabetes mellitus]];
'''EKG:''' [[Electrocardiogram]];
'''GDMT:''' Guideline-directed medical therapy;
'''HTN:''' [[Hypertension]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''LVH:''' [[Left ventricular hypertrophy]];
'''MI:''' [[Myocardial infarction]];
'''MRI:''' [[Magnetic resonance imaging]];
'''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
'''OCPs:''' [[Oral contraceptive pill]]s;
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]];
'''TSH:''' [[Thyroid stimulating hormone]]

 

{{familytree/start}}
{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:''' 
''Symptoms of fluid accumulation'' 
❑ [[Dyspnea]] 
:❑ At rest 
:❑ Exertional 
❑ [[Paroxysmal nocturnal dyspnea]] 
❑ [[Orthopnea]] 
❑ [[Cough]] 
❑ [[Peripheral edema]] 
❑ [[Ascites]] 
''Symptoms of reduced cardiac output'' 
❑ [[Fatigue]] 
❑ [[Oliguria]] 
❑ [[Dizziness]] 
❑ [[Syncope]] 
❑ [[Altered mental status]] 
❑ [[Cyanosis]] 
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]]) 
''Symptoms suggestive of precipitating events'' 
❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present) 
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s) 
❑ [[Fever]] (suggestive of [[sepsis]]) 
''Nonspecific symptoms'' 
❑ [[Anorexia]] 
❑ [[Bloating]] 
❑ [[Nausea]] 
❑ [[Weight loss]] 
----
'''Obtain a detailed history:''' 
❑ '''Past medical history''' 
:❑ [[Atrial fibrillation]] 
:❑ [[Cardiomyopathy]] 
:❑ [[Diabetes mellitus]] 
:❑ [[Hypertension]] 
:❑ [[Myocarditis]] 
:❑ [[myocardial infarction|Previous myocardial infarction]] 
:❑ [[Congestive heart failure|Prior heart failure]] 
:❑ [[Sleep apnea]] 
:❑ [[Thyroid disease]] 
:❑ [[Valvular heart disease]] 
❑ '''Medication history''' 
:❑ Noncompliance with previously prescribed medications for [[heart failure]] 
:❑ Intake of the following drugs: 
::❑ [[Alcohol]] 
::❑ [[Beta blockers]] 
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]] 
::❑ [[Chemotherapy]] drugs - [[anthracyclines]] 
::❑ [[NSAID]]s which should not be given in CHF 
::❑ [[Thiazolidinedione]] 
❑ '''Family history''' 
:❑ History of [[dilated cardiomyopathy]] 
❑ [[Radiation]] to the chest</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:''' 
'''General appearance:''' 
❑ Ill-looking 
❑ In respiratory distress 
❑ Usually in upright sitting position 

'''Vitals:''' 
❑ [[Temperature]] 
:❑ [[Fever]] (suggestive of underlying [[infection]]) 
❑ [[Pulse]] 
:❑ [[Tachycardia]] 
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg) 
❑ [[Blood pressure]] 
:❑ [[Hypotension]] (suggestive of circulatory collapse) 
:❑ [[Hypertension]] 
❑ [[Respiration]] 
:❑ [[Tachypnea]] (commonest symptom) 
❑ [[Pulse oximetry]] assure sat is > 90% 

'''Weight:''' 
❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and [[edema]] 

'''Skin''' 
❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]] 
❑ [[Cyanosis]], in severe [[hypoxemia]] 
❑ [[Anasarca]] 
'''Neck examination:''' 
❑ [[Jugular vein distention]] is often present 

'''Respiratory examination''' 
❑ [[Tachypnea]] 
❑ [[Wheeze]] (suggestive of cardiac asthma) 
❑ Dullness at lung bases, suggestive of [[pleural effusion]] 
❑ [[Crackles]]/[[crepitations]]/[[rales]] 

'''Cardiovascular examination''' 
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) 
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure) 
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both 
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s) 
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]] 
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]] 
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click 

'''Abdominal examination''' 
The following suggest volume overload and / or poor forward cardiac output: 
❑ [[Hepatojugular reflux]] 
❑ [[Hepatomegaly]] 
❑ [[Ascites]] 

'''Extremity examination''' 
❑ [[Pedal edema]] 

'''Neurological examination''' 
❑ [[Altered mental status]] 
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
{{familytree | | | | | | | | |!| | | | | |}}
{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': 
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) 
:❑ [[Troponin]]
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced 
::❑ [[Troponin|Troponin T]] ≥0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref>
:❑ [[Electrolytes]] 
::❑ Dilutional [[hyponatremia]] (with the presence of edema)
:❑ [[calcium|Serum calcium]] 
:❑ [[Magnesium|Serum magnesium]] which can be lowered by [[diuresis]] 
:❑ [[Serum bicarbonate]] to monitor [[contraction alkalosis]] with [[diuresis]]
:❑ [[BUN]], [[creatinine]] may be elevated due to poor renal perfusion 
:❑ [[Urinalysis]] 
:❑ [[Blood sugar|Fasting blood sugar]] 
:❑ [[Lipid profile|Fasting lipid profile]] 
:❑ [[Liver function tests]] 
:❑ [[Thyroid-stimulating hormone|TSH]] 
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain) 
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> 
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or 
:❑ NT-pro BNP ≤ 300 pg/mL 
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%) 
:❑ Cardiogenic [[pulmonary edema]] 
:❑ [[Kerley B lines]] 
:❑ [[Peribronchial cuffing]] 
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]]
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]] 
❑ [[EKG]] 
:❑ [[Low QRS voltage]] due to electrically inert [[myocardium]] 
:❑ [[Arrhythmia]] (usually [[atrial fibrillation]] which carries a poor prognosis and requires slowing to improve filling & [[cardiac output]]) 
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]]) 
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]]) 
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony 
:❑ [[Left atrial enlargement]] due to [[valvular disease]] or [[hypertension]] 
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]] 
❑ 2-D [[echocardiography]] with Doppler ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
:❑ Assess ventricular size, function, wall thickness, wall motion, and valve function 
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]] 
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate 
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]]) 
❑ [[Coronary angiography]] (in settings of ischemia) 
❑ [[Right heart catheterization|Pulmonary artery catheterization]] in [[respiratory distress]] or [[shock]] or to definitively assess volume status and tailor therapy 
----
'''Order additional tests to rule out other etiologies:''' 
❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases) 
❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]] 
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected)
</div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:''' 
----
<table class="wikitable">
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr>
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]] ❑ Reversal of symptoms following administration of [[bronchodilator]]s</td></tr>
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]] ❑ Bilateral opacities on [[chest X-ray]] ❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr>
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]] ❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr>
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]] ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr>
</table></div>}}
{{familytree | | | | | | | | |!| | |}}
{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy'''
</div>}}
{{familytree | | | | | | |,|-|^|-|.| | | | | |}}
{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' 
❑ '''Patients with structural heart disease''' 
This refers to patients with the following: 
:❑ Previous [[MI]] 
:❑ LV remodeling* (including [[ LVH]] + low [[EF]]) 
:❑ Asymptomatic [[valvular disease]] '''AND''' 
❑ '''Signs or symptoms of heart failure''' 
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div>
|X02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' 
❑ '''Refractory heart failure''' 
:❑ Marked symptoms at rest 
:❑ Recurrent hospitalizations</div>}}
{{familytree/end}}

==Treatment==
{{familytree/start}}
{{familytree | | | | | | | | C01 | | | | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initial stabilization:''' 
----
❑ Assess the [[airway]] 
❑ Position the patient upright at an angle of 45 degrees 
❑ Check [[pulse oximetry]] 
❑ If [[hypoxemia]] is present (Sa02 < 90% or Pa02 <60 mmHg)
:❑ Give [[oxygen]] by: 
::❑ Non-rebreather face masks 
::❑ [[Positive airway pressure|Continuous positive airway pressure]] 
:❑ Avoid [[morphine|IV morphine]] - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though 
❑ Ensure continuous cardiac monitoring 
❑ Secure intravenous access with 18 gauge canula 
❑ Monitor vitals signs 
❑ Monitor fluid intake and urine output
</div>}}
{{familytree | | | | | | | | |!| | | |}}
{{familytree | | | | | | | | E01 | | | |E01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission if the following is present:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref> 
----
❑ [[Hypotension]] and/or [[cardiogenic shock]] 
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] 
❑ [[Hypoxemia]] - Sa02 ↓90% 
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]] 
❑ Presence of an [[acute coronary syndrome]]</div>}}
{{familytree | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | H01 | |H01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treat precipitating causes/co-morbidities''' Click for detailed management 
----
❑ [[Aortic regurgitation resident survival guide|Acute aortic]]/[[Mitral regurgitation resident survival guide|mitral regurgitation]] 
❑ [[STEMI resident survival guide|Acute coronary syndrome]] 
❑ [[Anemia resident survival guide|Anemia]] 
❑ [[Aortic dissection resident survival guide|Aortic dissection]] 
❑ [[Atrial fibrillation resident survival guide|Atrial fibrillation]] 
❑ [[Hypertensive crisis resident survival guide|Hypertensive crisis]] 
❑ [[Acute kidney failure resident survival guide|Renal failure]] 
❑ [[Sepsis resident survival guide|Sepsis]]</div>}}
{{familytree | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | | I01 | | | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<ref name="pmid12767667">{{cite journal| author=Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH et al.| title=Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 10 | pages= 1797-804 | pmid=12767667 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12767667 }} </ref> 
❑ [[Congestion|Congestion at rest]] ('''dry vs. wet''') "Wet" suggested by [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]
 
❑ Low perfusion at rest ('''warm vs. cold''') "Cold" suggested by [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | |,|-|-|-|v|-|-|^|-|-|v|-|-|-|.| | |}}
{{familytree | J01 | | J02 | | | | J03 |~| J04 | | |J01=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Dry''' 
----
❑ Consider outpatient treatment ❑ Dietary sodium restriction (2-3 g daily) ❑ [[Smoking cessation]] ❑ [[Alcohol]] abstinence (≤2 standard drinks per day for men; ≤1 for women) ❑ Encourage exercise/physical activity 
'''Although [[ACE inhibitors]] and [[beta blockers]] should not be administered to patients with [[acute decompensated heart failure]], if the patient is compensated in the outpatient setting then administer: ❑ [[ACE inhibitors]] or ([[ARBs]]) if LVEF is ≤ 40% ❑ [[Beta blockers]]'''<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref> </div>|

J02=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Warm & Wet''' 
----
❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] 
❑ Treat co-morbidities [[HTN]], [[DM]], [[CAD]], [[AF]]</div>|

J03=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Wet''' 
----
❑ CCU admission 
❑ Invasive hemodynamic monitoring (arterial line, consider pulmonary catheter if volume status unclear) 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) ❑ [[Acute heart failure resident survival guide#Diuretic Therapy Details|Diuretic therapy]] while monitoring [[blood pressure]] ❑ IV vasodilators</div>|J04=<div style="float: left; text-align: left; width: 10em; padding:1em;">'''Cold & Dry''' 
----
❑ CCU admission 
❑ Intravenous inotropic drugs (e.g., [[dobutamine]]) 
❑ '''Persistent organ hypoperfusion''' (e.g., low urine output or persistent low SBP<85) 
:❑ [[Norepinephrine]] 0.2–1.0 mcg/kg/min, titrate to maintain a blood pressure of </div>}}
{{familytree | | | | | |!| | | | | |!| | | |!| | | | |}}
{{familytree | | | | | |`|-|-|v|-|-|^|-|-|-|'| | |}}
{{familytree | | | | | | | | X01 | | |X01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Indications for [[implantable cardioverter defibrillator]] (ICD)''' 
----
❑ As primary prevention of sudden cardiac death in: 
:❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
:❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III 
'''Contraindications''' 
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year 
❑ Incessant [[ventriculat tachycardia]] or [[ventricular fibrillation]] 
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up 
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or [[cardiac resynchronization therapy]] 
❑ [[Ventricular tachycardia]] due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) </div>}}
{{familytree | | | | | | | | |!| |}}
{{familytree | | | | | | | | K01 | | | |K01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ [[Low sodium diet]] 
❑ Monitor blood pressure, congestion, oxygenation 
❑ Daily weights using same scale after 1st void at same time of day 
❑ Intake and output charts 
❑ Convert all IV diuretic to oral forms in anticipation of discharge 
❑ '''Continue or initiate''' 
:❑ [[ACE inhibitors]] 
:❑ [[Beta blockers]] 
:❑ [[Omega-3 fatty acid]]<ref name="pmid18757090">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1223-30 | pmid=18757090 | doi=10.1016/S0140-6736(08)61239-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757090 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19172716 Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11] </ref> 
❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] 
❑ [[DVT prophylaxis]] 
❑ [[Influenza]] & [[Streptococcus pneumoniae|pneumococcal]] vaccination 
❑ Encourage [[physical activity]] in stable patients</div>}}
{{familytree | | | | | | | | |!| | | | | | |}}
{{familytree | | | | | | | | L01 | | | |L01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Discharge and follow-Up''' 
----
❑ Patient and family education 
❑ Prior to discharge, '''ensure''': 
:❑ Low salt diet 
:❑ Oral medication plan is stable for 24 hours 
:❑ No IV [[vasodilator]] or inotropic drugs for 24 hours 
:❑ Weighing scale is present in patient's home 
:❑ [[Smoking cessation]] counseling 
:❑ Follow-up clinic visit scheduled within 7 to 10 days
:❑ Ambulation prior to discharge to assess functional capacity 
❑ Telephone follow-up call usually 3 days post discharge 
❑ Potassium monitoring and repletion 
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
{{familytree/end}}

====Diuretic Therapy Details====
{{familytree/start}}
{{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
{{familytree | | | |!| |}}
{{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ [[Low sodium diet]] (<2 g daily) 
❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L 
❑ Initiate IV [[diuretics]] due to poor absorption from gut 
:❑ [[Frusemide]] 40 mg, or
:❑ [[Torsemide]] 20 mg, or
:❑ [[Bumetanide]] 1 mg 
'''Contraindications to IV Diuresis''' 
❑ [[Hypotension]] and [[cardiogenic shock]] 
'''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
</div>}}
{{familytree | | | |!| | | |}}
{{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
{{familytree | |,|-|^|-|.| | |}}
{{familytree | D01 | | D02 | |D01=Yes|D02=No}}
{{familytree | |!| | | |!| | |}}
{{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose and titrate according to patient's response or when the maximum dose is reached}}
{{familytree | |!| | | |!| | |}}
{{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
{{familytree | |!| |,|-|^|-|.| | |}}
{{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add''' 
❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]] '''or''' 
❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients 
'''Indications:''' 
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women 
❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2 
❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L 
❑ NYHA class II–IV HF with LVEF ≤ 35% 
 K+- sparing diuretic e.g [[amiloride]] or [[triamterene]] should not be administered with aldosterone antagonist given the risk of [[hyperkalemia]] </div>
|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics''' 
----
❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]] 
❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]] 
❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
{{familytree | |!| |`|-|v|-|'| |}}
{{familytree | |!| | | H01 | | |H01=No symptomatic improvement ('''refractory edema''')}}
{{familytree | |!| | | |!| |}}
{{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
{{familytree | |`|-|v|-|'| |}}
{{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures''' 
----
❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts 
❑ Convert all IV diuretic to oral ❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]] ❑ [[DVT prophylaxis]]</div>}}
{{familytree/end}}

==Primary Prevention==
{{familytree/start}}
{{familytree | | | | | A00 | | A00=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have stage A or stage B of heart failure according to the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]]?'''</div>}}
{{familytree | |,|-|-|-|+|-|-|-|.| | | | }}
{{familytree | A01 | | A02 | | A03 | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Yes, the patient has stage A'''
----
Therapeutic goals: 
❑ Promote healthy lifestyle 
❑ Prevent CAD and comorbidities 
❑ Prevent LV structural abnormalities</div>|A02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Yes, the patient has stage B'''
----
Therapeutic goal:
❑ Prevent symptoms of heart failure</div>
|A03=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''No, the patient does not belong to any of the stages'''
----
No preventive therapy is needed</div>}}
{{familytree | |!| | | |!| |}}
{{familytree | B01 | | B02 | | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ Control HTN and lipid disorders 
:❑ [[ACE inhibitors]] or ([[ARBs]]) in patients with vascular disease or DM 
:❑ [[Statins]] 
❑ Minimize risk factors
:❑ Dietary sodium restriction (2-3 g daily) 
:❑ [[Smoking cessation]] 
:❑ Alcohol abstinence (≤2 standard drinks per day for men; ≤1 for women) 
:❑ Encourage exercise/physical activity</div>|B02=<div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ Administer [[ACE inhibitors]] or ([[ARBs]]) in patients with: 
:❑ Prior [[MI]] and LVEF ≤40% to prevent heart failure ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) '''OR'''
:❑ LVEF ≤40% ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
❑ Administer [[beta blockers]] in patients with: 
:❑ Prior [[MI]] and LVEF ≤ 40% to prevent heart failure ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]]) 
:❑ LVEF ≤ 40% to prevent heart failure ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) 
❑ [[Statins]] 
:❑ Patients with MI ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]]) 
❑ Implantable cardioverter defibrillator (ICD) to prevent sudden death in: 
:❑ Asymptomatic ischemic cardiomyopathy ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence B]]) 
::❑ ≥ 40 day post-[[MI]] 
::❑ LVEF ≤ 30% 
::❑ On GDMT 
❑ The use of CCBs e.g., verapamil and diltiazem in patients with LVEF ≤ 30%</div>}}
{{familytree/end}}

====Medications====
{| class="wikitable sortable"
! Drug Class
! Drug
! Daily dose
! Maximum daily dose
|-
| [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>|| 600 mg
|-
| || [[Bumetanide]] || 0.5 to 1.0 mg once or twice || 10 mg
|-
| || [[Torsemide]]|| 10 to 20 mg once|| 200 mg
|-
| [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice|| 1000 mg
|-
| || [[Hydrochlorothiazide]] || 25 mg once or twice|| 200 mg
|-
| || [[Metolazone]] || 2.5 mg once|| 20 mg
|-
| K+- sparing diuretic|| [[Amiloride]] || 5 mg once|| 20 mg
|-
| || [[Spironolactone]] || 12.5 to 25.0 mg once|| 50 mg
|-
| || [[Triamterene]] || 50 to 75 mg twice|| 200 mg
|-
| [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice|| 10 to 20 mg twice
|-
| || [[Lisinopril]] || 2.5 to 5 mg once|| 20 to 40 mg once
|-
| || [[Ramipril]] ||1.25 to 2.5 mg once|| 10 mg once
|-
| [[ARBs]] || [[Candesartan]] || 4 to 8 mg once|| 32 mg once
|-
| || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
|-
| || [[Valsartan]] || 20 to 40 mg twice|| 160 mg twice
|-
| [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once|| 10 mg once
|-
| || [[Carvedilol]] || 3.125 mg twice|| 50 mg twice
|-
| || [[Metoprolol succinate]] || 12.5 to 25.0 mg once|| 200 mg once
|-
| [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once|| 25 mg once or twice
|-
| || [[Eplerenone]] || 25 mg once|| 50 mg once
|-
| Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min||
|-
| || [[Dobutamine]] || 2.5 to 5 mcg/kg/min||
|-
| || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min||
|-
| [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated||Max is 400mcg/min
|-
| || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion|| Max of 0.03 mcg/kg/minute
|-
| [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
|-
| ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses [[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily|| 120 mg daily in divided doses
|-
| [[Digoxin]] || || 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]||
|}

==Do's==
* Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of [[heart failure]] as defined by ACCF/AHA. These are primarily the '''class 1 recommendations'''. It involves the use of [[ACE inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
* Order an [[echocardiogram]] as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
* [[Digoxin]] decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include [[amiodarone]], [[quinidine]] and [[verapamil]]. <ref>The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.</ref><ref>Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.</ref><ref>Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.</ref>
* [[DVT prophylaxis]] unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
* Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
* Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
* Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>

==Don'ts==
* Avoid, if possible, [[NSAIDs]], [[Sympathomimetic amine|sympathomimetics]], [[tricyclic antidepressant]]s, class I and III antiarrhythmics (except [[amiodarone]]), and nondihydropyridine [[calcium channel blocker]]s ([[diltiazem]], [[verapamil]] as they can be harmful in acute decompensated [[HF]]. <ref>Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.</ref><ref>. Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inﬂammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.</ref><ref>Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3</ref><ref>Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.</ref><ref>The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and ﬂecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.</ref><ref>The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.</ref><ref>Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-beneﬁt ratio. Am Heart J. 1989;118:433–40.</ref>
* Don't administer parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
* Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|HFrEF]] unless otherwise indicated as this combination carries a risk of renal dysfunction and [[hyperkalemia]].
* Don't use [[aldosterone receptor antagonists]] in patients with [[hyperkalemia]] or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
* Don't use [[statins]] routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>

==References==
{{Reflist|2}}

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[[Category:Resident survival guide]]
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[[Category:Up-To-Date cardiology]]
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