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| | #Redirect [[Heart failure resident survival guide]] |
| __NOTOC__
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| {{CMG}}; {{AE}} {{AO}}
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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]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Classification|Classification]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Causes|Causes]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Diagnosis|Diagnosis]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Treatment|Treatment]]
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| :[[Chronic heart failure resident survival guide#Diuretic Therapy|Diuretic Therapy]]
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| :[[Chronic heart failure resident survival guide#Medications|Medications]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Do's|Do's]]
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| ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Chronic heart failure resident survival guide#Don'ts|Don'ts]]
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| |}
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| ==Overview==
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| 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]].
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| ====Goals of Therapy====
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| {|class="wikitable"
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| ! Goals!!Therapeutic intervention
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| |-
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| | To alleviate symptoms and signs||[[Diuretics]], [[morphine]] (no mortality benefit)
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| |-
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| | 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>
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| | 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>
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| |}
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| ==Classification==
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| ====Based on the Stage of Heart Failure====
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| {|class="wikitable"
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| ! ACCF/AHA Stages !! Description
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| | '''A'''|| At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
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| |-
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| | '''B'''|| Structural heart disease but without signs or symptoms of HF
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| |-
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| | '''C'''|| Structural heart disease with prior or current symptoms of HF
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| |-
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| | '''D'''|| Refractory HF requiring specialized interventions
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| |}
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| ''ACCF - American College of Cardiology Foundation; AHA - American Heart Association''
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| ====Based on the Severity of Congestive Heart Failure====
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| {|class="wikitable"
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| ! NYHA<br> classification!! Description
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| |-
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| | '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
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| |-
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| | '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
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| |-
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| | '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
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| |-
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| | '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
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| |}
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| ''NYHA - New York Heart Association''
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| ==Causes==
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| ===Life Threatening Causes===
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| [[Congestive heart failure|Chronic heart failure]] is life threatening and should be treated as such irrespective of the underlying cause.
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| ===Common Causes===
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| * Cardiotoxic drugs (e.g. [[NSAIDs]], [[thiazolidinedione]], and certain [[chemotherapy]] drugs)
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| * [[Sepsis|Concurrent infections]] e.g., [[pneumonia]], viral illnesses
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| * Electrolyte imbalances
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| * Endocrine abnormalities - [[diabetes mellitus]], thyroid disorders ([[hyperthyroidism]], [[hypothyroidism]])
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| * Excessive [[alcohol]] or illicit drug use (e.g. [[cocaine]])
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| * Medication noncompliance
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| * [[Myocardial ischemia]] or [[infarction]]
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| * Noncompliance with dietary restrictions (e.g., sodium and fluid restriction)
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| * Progressive valvular disease (e.g. [[mitral regurgitation]])
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| * [[Pulmonary embolus]]
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| * [[Cardiac arrhythmias|Uncontrolled arrhythmias]]
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| * [[Hypertension|Uncontrolled hypertension]]
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| ==Complete Diagnostic Approach==
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| 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>
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| <span style="font-size:85%">'''Abbreviations:'''
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| '''ARDS:''' Acute respiratory distress syndrome;
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| '''BNP:''' B-type natriuretic peptide;
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| '''BUN:''' Blood urea nitrogen;
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| '''CAD:''' Coronary artery disease;
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| '''CBC:''' Complete blood count;
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| '''CCB:''' Calcium channel blocker;
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| '''CT:''' Computed tomography;
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| '''CXR:''' Chest x-ray;
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| '''DM:''' Diabetes mellitus;
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| '''EKG:''' Electrocardiogram;
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| '''HTN:''' Hypertension;
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| '''LVEF:''' Left ventricular ejection fraction;
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| '''LVH:''' Left ventricular hypertrophy;
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| '''MI:''' Myocardial infarction;
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| '''MRI:''' Magnetic resonance imaging;
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| '''NT-pro BNP:''' N-terminal pro-brain natriuretic peptide;
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| '''OCPs:''' Oral contraceptive pills;
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| '''PAWP:''' Pulmonary artery wedge pressure
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| '''TSH:''' Thyroid stimulating hormone</span>
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| <br>
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| {{familytree/start}}
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| {{familytree | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Characterize the symptoms:'''<br>
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| '''Symptoms of fluid accumulation:'''<br>
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| ❑ [[Dyspnea]]<br>
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| :❑ At rest<br>
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| :❑ Exertional<br>
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| ❑ [[Paroxysmal nocturnal dyspnea]]<br>
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| ❑ [[Orthopnea]]<br>
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| ❑ [[Cough]]<br>
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| ❑ [[Peripheral edema]]<br>
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| ❑ [[Ascites]]<br>
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| '''Symptoms of reduced cardiac output:'''<br>
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| ❑ [[Fatigue]]<br>
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| ❑ [[Oliguria]]<br>
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| ❑ [[Dizziness]]<br>
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| ❑ [[Altered mental status]]<br>
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| ❑ [[Cyanosis]]<br>
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| ❑ [[Abdominal pain]] (may be suggestive of [[mesenteric ischemia]])<br>
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| '''Symptoms suggestive of precipitating events:'''<br>
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| ❑ [[Chest pain]] (if [[Coronary heart disease|myocardial ischemia]] is present)<br>
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| ❑ [[Palpitation]] (suggestive of [[arrhythmia]]s)<br>
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| ❑ [[Fever]] (suggestive of [[sepsis]])<br>
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| '''Nonspecific symptoms:'''<br>
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| ❑ [[Anorexia]]<br>
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| ❑ [[Bloating]]<br>
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| ❑ [[Nausea]]<br>
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| ❑ [[Weight loss]]<br>
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| '''Obtain a detailed history:'''<br>
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| ❑ '''Past medical history:'''<br>
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| :❑ [[Atrial fibrillation]]<br>
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| :❑ [[Cardiomyopathy]]<br>
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| :❑ [[Diabetes mellitus]]<br>
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| :❑ [[Hypertension]]<br>
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| :❑ [[Myocarditis]]<br>
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| :❑ [[myocardial infarction|Previous myocardial infarction]]<br>
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| :❑ [[Congestive heart failure|Prior heart failure]]<br>
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| :❑ [[Sleep apnea]]<br>
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| :❑ [[Thyroid disease]]<br>
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| :❑ [[Valvular heart disease]]<br>
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| ❑ '''Medication history:'''<br>
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| :❑ Noncompliance with medications<br>
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| :❑ Intake of the following drugs:<br>
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| ::❑ [[Alcohol]]<br>
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| ::❑ [[Beta blockers]]<br>
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| ::❑ [[Calcium channel blockers]]<br>
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| ::❑ [[Chemotherapy]] drugs - [[anthracyclines]]<br>
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| ::❑ [[NSAID]]s<br>
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| ::❑ [[Thiazolidinedione]]<br>
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| ❑ '''Family history:'''<br>
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| :❑ History of [[dilated cardiomyopathy]]<br>
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| ❑ [[Radiation]] to the chest</div>}}
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| {{familytree | | | | | |!| | |}}
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| {{familytree | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:'''<br>
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| '''General appearance:'''<br>
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| ❑ Ill-looking<br>
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| ❑ In respiratory distress<br>
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| ❑ Usually in upright sitting position<br>
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| '''Vitals:'''<br>
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| ❑ [[Temperature]]<br>
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| :❑ [[Fever]] (suggestive of underlying infection)<br>
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| ❑ [[Pulse]]<br>
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| :❑ [[Tachycardia]]<br>
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| :❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25 mmHg)<br>
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| ❑ [[Blood pressure]]<br>
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| :❑ [[Hypotension]] (suggestive of circulatory collapse)<br>
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| :❑ [[Hypertension]] <br>
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| ❑ [[Respiration]]<br>
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| :❑ [[Tachypnea]] (commonest symptom)<br>
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| ❑ [[Pulse oximetry]]<br>
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| '''Assess weight:'''<br>
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| :❑ Subtract 'dry weight' from value to assess [[edema]]<br>
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| '''Skin:'''<br>
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| ❑ [[Cool extremities|Cool and clammy]], in hypoperfusion or [[cardiogenic shock]]<br>
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| ❑ [[Cyanosis]], in severe [[hypoxemia]]<br>
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| ❑ [[Anasarca]]<br>
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| '''Neck examination:'''<br>
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| ❑ [[Jugular vein distention]]<br>
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| '''Respiratory examination:'''<br>
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| ❑ [[Tachypnea]]<br>
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| ❑ [[Wheeze]] (suggestive of cardiac asthma)<br>
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| ❑ Dullness at lung bases, suggestive of [[pleural effusion]]<br>
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| ❑ [[Crackles]]/[[crepitations]]/[[rales]]<br>
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| '''Cardiovascular examination:'''<br>
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| ❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]])<br>
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| ❑ [[Parasternal heave]] (when right ventricular pressure is increased)<br>
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| ❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both<br>
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| ❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s)<br>
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| :❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]]<br>
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| :❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]]<br>
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| :❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click<br>
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| '''Abdominal examination:'''<br>
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| ❑ [[Hepatojugular reflux]]<br>
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| ❑ [[Hepatomegaly]]<br>
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| ❑ [[Ascites]]<br>
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| '''Extremity examination:'''<br>
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| ❑ [[Pedal edema]]<br>
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| '''Neurological examination:'''<br>
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| ❑ [[Altered mental status]]<br>
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| ❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]])</div>}}
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| {{familytree | | | | | |!| | |}}
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| {{familytree | | | | | Q01 | |Q01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': <br>
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| '''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<br>
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| :❑ [[Complete blood count|CBC]] (rule out [[anemia]]) <br>
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| :❑ [[Troponin]]
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| ::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema<br>
| |
| ::❑ [[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><br>
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| :❑ [[Electrolytes]]<br>
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| ::❑ Dilutional [[hyponatremia]] (with the presence of edema)
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| :❑ [[calcium|Serum calcium]]<br>
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| :❑ [[Magnesium|Serum magnesium]]<br>
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| :❑ [[BUN]], [[creatinine]]<br>
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| :❑ [[Urinalysis]] <br>
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| :❑ [[Blood sugar|Fasting blood sugar]]<br>
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| :❑ [[Lipid profile|Fasting lipid profile]]<br>
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| :❑ [[Liver function tests]]<br>
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| :❑ [[Thyroid-stimulating hormone|TSH]] <br>
| |
| ❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP<br>
| |
| 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> <br>
| |
| :❑ [[B-type natriuretic peptide|BNP]] ≤ 35 pg/mL<br>
| |
| :❑ NT-pro BNP ≤ 125 pg/mL <br>
| |
| ❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<br>
| |
| :❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%)<br>
| |
| :❑ Cardiogenic [[pulmonary edema]]<br>
| |
| :❑ [[Kerley B lines]]<br>
| |
| :❑ [[Peribronchial cuffing]]<br>
| |
| :❑ Cephalization
| |
| [[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]]<br>
| |
| ❑ [[EKG]]<br>
| |
| :❑ [[Low QRS voltage]]<br>
| |
| :❑ [[Arrhythmia]] (usually [[atrial fibrillation]])<br>
| |
| :❑ [[Poor R wave progression]] (suggestive of a prior MI)<br>
| |
| :❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]])<br>
| |
| :❑ [[Left bundle branch block]] (LBBB)<br>
| |
| :❑ [[Left atrial enlargement]]<br>
| |
| :❑ Non-specific [[ST segment]] and [[T wave]] changes<br>
| |
| ❑ 2-D [[echocardiography]] with doppler <br> ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])
| |
| :❑ Ventricular size, function, wall thickness, wall motion, and valve function<br>
| |
| ❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]]<br>
| |
| :❑ To assess LVEF and volume when [[echocardiography]] is inadequate<br>
| |
| :❑ To assess myocardial infiltrative processes or scar burden ([[MRI]])<br>
| |
| ❑ [[Coronary angiography]] (in settings of ischemia)<br>
| |
| ❑ [[Right heart catheterization|Pulmonary artery catheterization]] - in [[respiratory distress]] or [[shock]]<br>
| |
| '''Additional tests to rule out other etiologies:'''<br>
| |
| ----
| |
| ❑ [[Antinuclear antibodies|ANA]], [[rheumatoid factor]] (for rheumatologic diseases)<br>
| |
| ❑ Diagnostic tests for [[hemochromatosis]], [[pheochromocytoma]]<br>
| |
| ❑ [[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:'''<br>
| |
| ----
| |
| <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<br>❑ [[Spirometry]] reveals obstructive pattern</td></tr>
| |
| <tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]]<br>❑ CXR - [[Pneumonia chest x ray|consolidation]]</td></tr>
| |
| <tr><td> [[Liver cirrhosis]]</td><td>❑ [[Jaundice]], [[fatigue]], [[peripheral edema]], [[coagulopathy]]<br>❑ Abnormal [[liver function tests]]<br>❑ [[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]]<br>❑ Risk factors - trauma, immobilization, smoking, OCPs <br>❑ CT pulmonary angiography - clot in pulmonary artery</td></tr>
| |
| <tr><td>[[Peripartum cardiomyopathy]] </td><td>❑ [[Dyspnea]], [[orthopnea]], [[PND]]<br>❑ [[Pregnancy]]<br>❑ Absence of heart disease prior to onset of heart failure<br>❑ [[Echocardiography]] confirms [[left ventricular enlargement]] and [[systolic dysfunction]]</td></tr>
| |
| <tr><td>[[Nephrotic syndrome]] </td><td>❑ [[Dyspnea]], [[fatigue]], [[peripheral edema]]<br>❑ [[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><br>
| |
| ----
| |
| ❑ [[Hypotension]] and/or [[cardiogenic shock]] <br>
| |
| ❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] <br>
| |
| ❑ [[Hypoxemia]] - Sa02 ↓90%<br>
| |
| ❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]]<br>
| |
| ❑ 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'''<br>
| |
| ❑ [[Congestion|Congestion at rest]]<br>e.g., [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]<br>
| |
| ❑ Low perfusion at rest <br>e.g., [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
| |
| {{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
| |
| {{familytree | | | | | Z01 | | | |Z01='''Does the patient have any<br> 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:'''<br>
| |
| ❑ [[Aldosterone]] or [[eplerenone]] if:<br>
| |
| :❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women<br>
| |
| :❑ Estimated [[glomerular filtration rate]] >30 mL/min/1.73 m2<br>
| |
| :❑ [[Potassium|Serum potassium]] ≤ 5.0 mEq/L <br>
| |
| :❑ NYHA class II–IV HF with LVEF ≤ 35%<br>'''OR'''<br>
| |
| ❑ [[Hydralazine]]/[[isosorbide dinitrate]]<br>
| |
| :❑ African Americans with NYHA class III–IV HFrEF on GDMT<br>'''OR'''<br>
| |
| ❑ [[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% <br>
| |
| ❑ Sinus rhythm or [[Left bundle branch block|LBBB]]<br>
| |
| ❑ [[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)<br> ± [[Implantable cardioverter defibrillator]] (ICD)|R02=<div style="float: left; text-align: left; width: 15em; padding:1em;">[[Implantable cardioverter defibrillator]]<br>
| |
| ❑ As primary prevention of [[sudden cardiac death]] in:
| |
| :❑ Post [[MI]] with LVEF ≤ 35%, NYHA II or III on chronic GDMT<br>
| |
| :❑ Post [[MI]] with LVEF ≤ 30%, NYHA I on chronic GDMT<br></div>|R03=Continue GDMT}}
| |
| {{familytree | |`|-|v|-|'| | |}}
| |
| {{familytree | | | S01 | | |S01=Persistent symptoms<br>(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>:'''<br>
| |
| * [[Intra-aortic balloon pump]]<br>
| |
| * [[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><br>
| |
| ❑ General indications:
| |
| :❑ LVEF ≤ 25%<br>
| |
| :❑ NYHA III or IV on chronic GDMT <br>
| |
| :❑ 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)<br>
| |
| ❑ 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<br>
| |
| ❑ Commence IV [[diuretics]]<br>
| |
| :❑ [[Frusemide]] 40 mg, or
| |
| :❑ [[Torsemide]] 20 mg, or
| |
| :❑ [[Bumetanide]] 1 mg<br>
| |
| '''Contraindications'''<br>
| |
| ❑ [[Hypotension]] and [[cardiogenic shock]]<br><br>
| |
| '''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 <br>and titrate according to patient's response <br>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'''<br>
| |
| ❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]]<br>'''or'''<br>
| |
| ❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients</div><br>
| |
| |G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics'''<br>
| |
| | |
| ----
| |
| ❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]]<br>
| |
| ❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]]<br>
| |
| ❑ 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<br>('''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'''<br>
| |
| ----
| |
| ❑ Monitor BP, volume status, congestion<br>❑ Daily weights<br>❑ Intake and output charts<br>
| |
| ❑ Convert all IV diuretic to oral<br>❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]]<br>❑ 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 <br>In HF patients on loop diuretic, the initial IV dose should <br>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<sup>+</sup>- 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
| |
| |-
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| | Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min
| |
| |-
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| | || [[Dobutamine]] || 2.5 to 5 mcg/kg/min
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| |-
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| | || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min
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| |-
| |
| | [[Vasodilators]] || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min <br>every 3-5 mins as tolerated, max is 400mcg/min
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| |-
| |
| | || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min <br>every 5 mins as tolerated, max is 400mcg/min
| |
| |-
| |
| | || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion,<br> maximum of 0.03 mcg/kg/minute
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| |-
| |
| | [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, <br>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<br>[[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>
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| ==References==
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| {{Reflist|2}}
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