Heart failure resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahmoud Sakr, M.D. [2]; Ayokunle Olubaniyi, M.B,B.S [3]

Acute Heart Failure Resident Survival Guide Microchapters
Overview
Classification
Causes
FIRE
Diagnosis
Treatment
Stage C
Stage D
Diuretic Therapy
Medications
Prevention
Stage A & B
Do's
Don'ts

Overview

Heart failure is a complex syndrome whereby there is inadequate output of the heart to meet the metabolic demands of the body. Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure. The clinical presentation include dyspnea, swelling of the legs, fatigue, and rales on physical examination. The diagnosis is mainly clinical, coupled with investigations such as chest X-ray, EKG, echocardiography, and the measurement of the B-type natriuretic peptide (BNP). The aims of the treatment is the symptomatic relief through the administration of oxygen, diuresis and morphine as well as the reduction of morbidity and mortality through the administration of ACE inhibitors or angiotensin II receptor blockers, beta blockers, aldosterone antagonists, and hydralazine/nitrate.

Classification

Based on the Stage of Heart Failure

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

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 Left Ventricular Ejection Fraction (LVEF)

Causes

Life Threatening Causes

Acute decompensated heart failure is life threatening and should be treated as such irrespective of the underlying cause.

Common Causes

Click 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 salmon color signify that an urgent management is needed.

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

 
 
Identify cardinal signs and symptoms that increase the pretest probability of acute heart failure

❑ Past medical history of heart failure
❑ History of orthopnea and paroxysmal nocturnal dyspnea
Symptoms

Dyspnea
Chest pain

Signs

❑ Pulmonary crepitations/rales/crackles
Cool extremities
Peripheral edema
Third heart sound (S3)
 
 
 
 
 
 
 
 
 
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
Cold and clammy extremities
Oliguria (urine output <0.5mL/kg/hr)

Metabolic acidosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
Treat cardiogenic shock

❑ Admit intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring
❑ Initiate oxygen therapy
❑ For SBP 85 - 100 mm Hg

❑ Consider dobutamine or milrinone

❑ For SBP < 85 mm Hg

❑ Consider dopamine and norepinephrine

❑ Consider intra-aortic balloon pump, if hypotension persists
❑ Consider left ventricular assist devices

Click here for cardiogenic shock resident survival guide
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urgent treatment

Diuretic therapy (click for details)
Administer IV morphine
Administer oxygen by:

❑ Non-rebreather face masks
Continuous positive airway pressure
❑ Noninvasive positive pressure ventilation (NPPV)
❑ Mechanical ventilation (PEEP)
Administer IV vasodilators e.g.,nitroglycerin, nesiritide
 

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.[1][2]

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


 
 
 
 
 
 
 
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 (suggestive of mesenteric ischemia)
Symptoms suggestive of precipitating events
Chest pain (if myocardial ischemia is present)
Palpitation (suggestive of arrhythmias)
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
Previous myocardial infarction
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
Chemotherapy drugs - anthracyclines
NSAIDs
Thiazolidinedione

Family history

❑ History of dilated cardiomyopathy
Radiation to the chest
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

General appearance:
❑ Ill-looking
❑ In respiratory distress
❑ Usually in upright sitting position

Vitals:
Temperature

Fever (suggestive of underlying infection)

Pulse

Tachycardia
Narrow pulse pressure (<25 mmHg)

Blood pressure

Hypotension (suggestive of circulatory collapse)
Hypertension

Respiration

Tachypnea (commonest symptom)

Pulse oximetry

Weight:
❑ Subtract 'dry weight' from current weightto assess edema

Skin
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 (suggestive of elevated right ventricular pressure)
S3 (typical) or S4 or both
❑ New or changed murmur (suggestive of an underlying valvular heart diseases)

Mitral regurgitation - Holosystolic murmur
Aortic regurgitation - 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)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order tests:

Routine (Class I, level of evidence C)

CBC (rule out anemia)
Troponin
❑ Elevated in myocardial ischemia and acute cardiogenic pulmonary edema
Troponin T ≥0.1 ng/mL (associated with poor survival)[3]
Electrolytes
❑ Dilutional hyponatremia (with the presence of edema)
Serum calcium
Serum magnesium
BUN, creatinine
Urinalysis
Fasting blood sugar
Fasting lipid profile
Liver function tests
TSH

BNP or NT-pro BNP (if diagnosis is uncertain)
Heart failure is unlikely if:[4][5]

BNP ≤ 100 pg/mL, or
❑ NT-pro BNP ≤ 300 pg/mL

Chest X-ray (Class I, level of evidence C)

Cardiomegaly (cardiothoracic ratio >50%)
❑ Cardiogenic pulmonary edema
Kerley B lines
Peribronchial cuffing
Cephalization
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
(Class I, level of evidence C)

❑ Ventricular size, function, wall thickness, wall motion, and valve function

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)
Pulmonary artery catheterization in respiratory distress or shock


Order additional tests to rule out other etiologies:
ANA, rheumatoid factor (for rheumatologic diseases)
❑ Diagnostic tests for hemochromatosis, pheochromocytoma
Endomyocardial biopsy (when myocarditis is suspected)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnoses:

Alternative diagnosesFeatures
Acute asthmaWheeze
❑ Reversal of symptoms following
administration of bronchodilators
ARDS❑ Severe hypoxia
❑ Bilateral opacities on chest X-ray
PCWP < 15 mmHg
PneumoniaFever, cough, sputum
Consolidation on chest X-ray
Pulmonary embolismPleuritic chest pain, cough, S4
❑ Risk factors: trauma, immobilization, smoking, OCPs
❑ Clot in pulmonary artery on CT pulmonary angiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
What is the stage of heart failure using the ACCF/AHA staging system?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
Stage B

Patients with structural heart disease

❑ Previous MI
❑ LV remodelling - LVH + low EF
❑ Family history of cardiomyopathy
❑ Asymptomatic valvular disease


AND

No sign or symptom of heart failure
 
Stage C

Patients with structural heart disease


AND

Signs or symptoms of heart failure
 
Stage D

Refractory heart failure

❑ Marked symptoms at rest
❑ Recurrent hospitalizations
 

Treatment

 
 
 
 
 
 
 
Initial stabilization:

❑ Assess the airway
❑ Position the patient upright at an angle of 45 degrees
Pulse oximetry
❑ If hypoxemia is present (Sa02 < 90% or Pa02 <60 mmHg)

❑ Give oxygen by:
❑ Non-rebreather face masks
Continuous positive airway pressure
❑ Give IV morphine - no mortality benefit and generally not advisable

❑ Continuous cardiac monitoring
❑ Intravenous access
❑ Monitor vitals signs
❑ Monitor fluid intake and urine output

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider admission if the following is present:[6]

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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat precipitating causes/co-morbidities
Click for detailed management

Acute aortic/mitral regurgitation
Acute coronary syndrome
Anemia
Aortic dissection
Atrial fibrillation
Hypertensive crisis
Renal failure

Sepsis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess hemodynamic and volume status[7]

Congestion at rest (dry vs. wet)
e.g., orthopnea, ↑JVP, rales, S3, pedal edema

❑ Low perfusion at rest (warm vs. cold)
e.g., narrow pulse pressure, cool extremities, hypotension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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)


ACE inhibitors or (ARBs) if LVEF is ≤ 40%
Beta blockers[8]
❑ Encourage exercise/physical activity
 
Warm & Wet

Diuretic therapy

❑ Treat co-morbidities - HTN, DM, CAD, AF
 
 
 
Cold & Wet

❑ CCU admission
❑ Invasive hemodynamic monitoring (central, arterial line, pulmonary catheter)

❑ Intravenous inotropic drugs (e.g., dobutamine)
Diuretic therapy while monitoring blood pressure
❑ IV vasodilators
 
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 for best response
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
General measures

Low sodium diet
❑ Monitor blood pressure, congestion, oxygenation
❑ Ensure daily weights
❑ Intake and output charts
❑ Convert all IV diuretic to oral forms
Continue or initiate

ACE inhibitors
Beta blockers
Omega-3 fatty acid[9]

❑ Daily serum electrolytes, urea & creatinine
❑ DVT prophylaxis
Influenza & pneumococcal vaccination

❑ Encourage physical activity in stable patients
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 

Diuretic Therapy

 
 
Evidence of volume overload
 
 
 
 
 
 
 
 
 

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)

 
 
 
 
 
 
 
 
 
 
 
Symptomatic improvement?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
Maintain current IV diuretic dose
 
Double IV diuretic dose
and titrate according to patient's response
or when the maximum dose is reached
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No symptomatic improvement
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Add

❑ Another diuretic e.g., IV chlorothiazide or oral metolazone
or

❑ An aldosterone antagonist e.g., spironolactone or eplerenone, in post MI patients

 
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) [10] [11]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No symptomatic improvement
(refractory edema)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ultrafiltration or dialysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 


Primary Prevention

 
 
 
 
Does the patient have stage A or stage B of heart failure according to the ACCF/AHA staging system?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes, the patient has stage A

Therapeutic goals:
❑ Promote healthy lifestyle
❑ Prevent CAD and comorbidities

❑ Prevent LV structural abnormalities
 
Yes, the patient has stage B

Therapeutic goal:

❑ Prevent symptoms of heart failure
 
No, the patient does not belong to any of the stages
No preventive therapy is needed
 
 
 
 
 
 
 
 
 
 

❑ 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
 

ACE inhibitors or (ARBs)

❑ History of MI and LVEF ≤40% (Class I, level of evidence A)
❑ All patients with LVEF ≤40% (Class I, level of evidence A)

Beta blockers

❑ Patients with MI and LVEF ≤ 40% (Class I, level of evidence B)

Statins

❑ Patients with MI (Class I, level of evidence A)

❑ Implantable cardioverter defibrillator (ICD) to prevent sudden death in:

❑ Asymptomatic ischemic cardiomyopathy (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%
 
 

Medications

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.[12]
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

  • 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 inhibitors or (ARBs), beta blockers, aldosterone antagonists, and hydralazine/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. It can be beneficial in symptomatic patients with low EF.[13][14][15][16][17][18][19]
  • Ensure DVT prophylaxis unless contraindicated.[20][21]
  • Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.[22][23]
  • 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 .[24][25]

Don'ts

References

  1. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH; et al. (2013). "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". Circulation. 128 (16): 1810–52. doi:10.1161/CIR.0b013e31829e8807. PMID 23741057.
  2. Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG; et al. (2009). "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". J Am Coll Cardiol. 53 (15): e1–e90. doi:10.1016/j.jacc.2008.11.013. PMID 19358937.
  3. Perna, ER.; Macín, SM.; Parras, JI.; Pantich, R.; Farías, EF.; Badaracco, JR.; Jantus, E.; Medina, F.; Brizuela, M. (2002). "Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema". Am Heart J. 143 (5): 814–20. PMID 12040342. Unknown parameter |month= ignored (help)
  4. McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K; et al. (2012). "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". Eur Heart J. 33 (14): 1787–847. doi:10.1093/eurheartj/ehs104. PMID 22611136.
  5. Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A; et al. (2006). "The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure". Br J Gen Pract. 56 (526): 327–33. PMC 1837840. PMID 16638247.
  6. 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 (2010). "HFSA 2010 Comprehensive Heart Failure Practice Guideline". Journal of Cardiac Failure. 16 (6): e1–194. doi:10.1016/j.cardfail.2010.04.004. PMID 20610207. Retrieved 2013-04-29. Unknown parameter |month= ignored (help)
  7. Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH; et al. (2003). "Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure". J Am Coll Cardiol. 41 (10): 1797–804. PMID 12767667.
  8. Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA (2007). "Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET". European Journal of Heart Failure. 9 (9): 901–9. doi:10.1016/j.ejheart.2007.05.011. PMID 17581778. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  9. Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG; et al. (2008). "Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial". Lancet. 372 (9645): 1223–30. doi:10.1016/S0140-6736(08)61239-8. PMID 18757090. Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11
  10. Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A; et al. (2004). "Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial". JAMA. 291 (16): 1963–71. doi:10.1001/jama.291.16.1963. PMID 15113814.
  11. Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I; et al. (2001). "Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure". Circulation. 104 (20): 2417–23. PMID 11705818.
  12. 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 (2011). "Diuretic strategies in patients with acute decompensated heart failure". The New England Journal of Medicine. 364 (9): 797–805. doi:10.1056/NEJMoa1005419. PMC 3412356. PMID 21366472. Retrieved 2013-04-30. Unknown parameter |month= ignored (help)
  13. 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.
  14. 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
  15. 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.
  16. Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.
  17. . 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.
  18. 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.
  19. 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.
  20. Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A; et al. (2003). "Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study". Blood Coagul Fibrinolysis. 14 (4): 341–6. PMID 12945875.
  21. Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel (2012). "Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): 7S–47S. doi:10.1378/chest.1412S3. PMC 3278060. PMID 22315257.
  22. Grosskopf I, Rabinovitz M, Rosenfeld JB (1986). "Combination of furosemide and metolazone in the treatment of severe congestive heart failure". Isr J Med Sci. 22 (11): 787–90. PMID 3793436.
  23. Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR (2005). "Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature". Cardiovasc Drugs Ther. 19 (4): 301–6. doi:10.1007/s10557-005-3350-2. PMID 16189620.
  24. Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI (2000). "Predictors of readmission among elderly survivors of admission with heart failure". Am Heart J. 139 (1 Pt 1): 72–7. PMID 10618565.
  25. Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW; et al. (2010). "Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure". JAMA. 303 (17): 1716–22. doi:10.1001/jama.2010.533. PMID 20442387.
  26. 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.
  27. . 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.
  28. 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
  29. 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.
  30. 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.
  31. 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.
  32. 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.
  33. 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 (2002). "Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial". JAMA : the Journal of the American Medical Association. 287 (12): 1541–7. PMID 11911756. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  34. Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A; et al. (2004). "Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study". N Engl J Med. 351 (6): 543–51. doi:10.1056/NEJMoa040135. PMID 15295047.
  35. Bozkurt B, Agoston I, Knowlton AA (2003). "Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines". J Am Coll Cardiol. 41 (2): 211–4. PMID 12535810.
  36. Horwich TB, MacLellan WR, Fonarow GC (2004). "Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure". J Am Coll Cardiol. 43 (4): 642–8. doi:10.1016/j.jacc.2003.07.049. PMID 14975476.
  37. Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG; et al. (2008). "Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial". Lancet. 372 (9645): 1231–9. doi:10.1016/S0140-6736(08)61240-4. PMID 18757089.


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