Heart failure resident survival guide

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]

Definitions

	Definition
Heart failure	This is a complex syndrome whereby there is inadequate output of the heart to meet the metabolic demands of the body. Heart failure is a clinical syndrome characterized by symptoms of dyspnea, edema and fatigue and signs such as rales on physical examination.
Heart failure with preserved ejection fraction (HFpEF)	This is otherwise called diastolic HF. It is characterized with an ejection fraction ≥ 50%.
Heart failure with reduced ejection fraction (HFrEF)	This is also called systolic HF. It is characterized with an ejection fraction of ≤ 40%.
Advanced heart failure
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.

Causes

Life Threatening Causes

Acute decompensated heart failure is a life-threatening condition and must be treated as such irrespective of the causes. Life-threatening conditions can result in death or permanent disability within 24 hours if left untreated.

• Accelerated hypertension
• Acute kidney injury
• Acute myocardial ischemia
• Acute or progressive valvular disease (e.g. acute mitral regurgitation)
• Acute or subacute valve disease endocarditis
• Aortic dissection
• Cardiac arrhythmias, specially ventricular arrhythmias
• Cardiotoxic agents (e.g. alcohol, cocaine, and certain chemotherapy drugs)
• Diabetic emergencies (e.g. ketoacidosis)
• Myopericarditis
• Pulmonary embolus
• Severe anemia (e.g. acute hemolysis or blood loss)
• Systemic Inflammatory response syndrome
• Thyrotoxicosis

Common Causes

• Accelerated hypertension
• Acute kidney injury
• Acute myocardial ischemia
• Acute or progressive valvular disease (e.g. acute mitral regurgitation)
• Cardiac arrhythmias
• Excessive alcohol or illicit drug use (e.g. cocaine)
• Myocardial ischemia (e.g. AF)
• Pulmonary embolus
• Systemic Inflammatory response syndrome

Management

Characterize the symptoms: ❑ Cardiac ❑ Chest pain ❑ Cough ❑ Dyspnea at rest ❑ Exertional dyspnea ❑ Orthopnea ❑ Palpitation ❑ Paroxysmal nocturnal dyspnea ❑ Peripheral edema ❑ Extracardiac ❑ Anorexia ❑ Bloating ❑ Fatigue ❑ Nausea ❑ Oliguria ❑ Weight loss Obtain a detailed history: ❑ Medications: ❑ Alcohol ❑ Beta blockers ❑ Calcium channel blockers ❑ Chemotherapy drugs - anthracyclines ❑ NSAIDs ❑ Thiazolidinedione ❑ Past medical history ❑ Arrhythmias ❑ Cardiomyopathy ❑ Diabetes mellitus ❑ Hypertension ❑ Obesity ❑ Previous myocardial infarction ❑ Sleep disorders ❑ Thyroid disease ❑ Valvular heart disease ❑ Family history ❑ History of dilated cardiomyopathy ❑ Radiation to the chest

Examine the patient: ❑ General examination: ❑ Pulse rate - ↑ ❑ Blood pressure - ↑ or ↓ ❑ Respiratory rate - ↑ ❑ Weight ❑ Head/neck examination: ❑ ↑ JVP ❑ Cardiovascular examination: ❑ Wheeze (cardiac asthma) ❑ S3 or S4 or both ❑ New or changed murmur ❑ Respiratory examination ❑ Crackles ❑ Abdominal examination: ❑ Hepatomegaly ❑ Ascites ❑ Neurological examination: ❑ Altered mental status ❑ Extremity examination: ❑ Pedal edema ❑ Assess severity - NYHA or ACC/AHA scales Consider close differential diagnoses: ❑ Acute asthma ❑ Acute respiratory distress syndrome ❑ Cardiac tamponade ❑ Pneumonia ❑ Pulmonary embolism

Initial stabilization: ❑ Assess airway, pulse oximetry ❑ Nurse 45 degrees upright ❑ Give oxygen, if Sa02 ↓90% by non-rebreather face masks ❑ Continuous cardiac monitoring ❑ Intravenous access ❑ Monitor vitals - Pulse, BP ❑ Monitor urine output ❑ Order ❑chest x ray ❑ Cardiomegaly ❑ Pulmonary edema ❑ Kerley B lines ❑EKG ❑ Evidence of ischemia ❑ Infarction ❑ Arrythmia ❑ Left ventricular hypertrophy

Order laboratory tests: ❑ CBC ❑ Troponin ❑ Electrolytes - ↓Na ❑ serum calcium ❑ serum magnesium ❑ BUN, creatinine - ↑ ❑ Arterial blood gas ❑ Fasting blood sugar ❑ Liver function tests ❑ BNP or NT-pro BNP (if diagnosis is uncertain) Other additional laboratory tests: ❑ TSH ❑ Urinalysis ❑ ANA, rheumatoid factor ❑ Diagnostic tests for hemochromatosis, pheochromocytoma ❑ Radionuclide ventriculography or MRI ❑ Coronary angiography ❑ Endomyocardial biopsy ❑ Pulmonary artery catheterization - in respiratory distress or shock

Consider admission: ❑ 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

Acute treatment

Persistent respiratory distress ❑ Noninvasive positive pressure ventilation (NPPV) ↓ ↓ ❑ Mechanical ventilation (PEEP)

Cardiogenic shock ❑ Address emergently (ICU or CCU)(e.g. intubate, IV inotropes (e.g.dobutamine 2-20mcg/kg/min IV) ❑ IV vasoconstrictor ( e.g. Norepinephrine 0.2–1.0 mcg/kg/min, titrate for best response

Treat precipitating causes/co-morbidities ❑ Acute aortic/mitral regurgitation ❑ Acute coronary syndrome ❑ Anemia ❑ Atrial dissection

Assess hemodynamic and volume status (± Congestion & Poor perfusion)

Warm & Dry ❑ Continue GDMT ❑ Continue evidence-based beta-blockers ( i.e., bisoprolol, carvedilol, and sustained release metoprolol succinate)

Warm & Wet ❑ Salt restriction ❑ Continue GDMT while watching BP. ❑ Early loop diuretics (e.g. furosemide 20-40mg IV stat, titrate dose considering (SBP, BUN/CR, Prior use) - Consider ultrafiltration for refractory congestion

Cold & Wet ❑ Rapid intervention ❑ CCU admission ❑ Invasive hemodynamic monitoring (Central, arterial line, pulmonary catheter) ❑ Intravenous inotropic drugs (e.g.dobutamine 2-20mcg/kg/min IV) ❑ In countries where it is available, early levosimendan infusion can be considered ( SBP has to be >100 mm Hg) I.V.: Loading dose: 6-24 mcg/kg over 10 minutes followed by a continuous infusion of 0.05-0.2 mcg/kg/minute

Cold & Dry ❑ CCU admission ❑ Intravenous inotropic drugs (e.g.dobutamine 2-20mcg/kg/min IV)

Monitoring

Discharge and follow-up

-Figure 1: Approach to patients presenting with acutely decompensated HF.

- Focused history (e.g. dyspnea, orthopnea, edema, altered mentation, Hx of HF, Hx of drug abuse) - Vital signs - Physical exam [e.g. assess volume status (e.g. rales, edema, JVD) and perfusion (e.g. narrow pulse pressure, cold clammy extremities) ] - Initial labs to include: BNP and troponins - EKG - Chest X-ray

- Non-invasive monitoring (SaO2, BP, temperature)+ Oxygen therapy - IV furosemide 20-40mg stat, may repeat dose based on clinical response, BP, prior diuretic use - NIPPV (e.g. CPAP) if dyspnea not improved

- Patient is in shock or respiratory failure; Address emergently (ICU or CCU)(e.g. intubate, IV inotropes (e.g.dobutamine 2-20mcg/kg/min IV) IV vasoconstrictor ( e.g. Norepinephrine 0.2–1.0 mcg/kg/min, titrate for best response.)

- Hemodynamically stable acute HF (Data exist to support early and aggressive treatment in the first 6–12 hrs may result in more favorable outcomes.)

- Accelerated HTN; IV vasoactive therapy (e.g. IV NTG drip 10–20 mcg/min, increased in increments of 5–10 mcg/min every 3–5 mins as needed)

- Acute myocardial ischemia

- Atrial fibrillation

- No precipitating factors identified

- Renal injury "carries poor prognosis"

- Other etiologies (e.g. sepsis, pulmonary embolus)

- Oxygen, Nitrates, Morphine for chest pain, anticoagulation ( e.g. enoxaparin 1mg/kg sc stat), antiplatelets (e.g. aspirin 325mg stat+clopidogrel 300mg stat), GDMT(e.g. ACEI, ARBs, Aldosterone antagonists, diuretics) - Urgent revascularization - Refer to Acute coronary syndrome resident survival guide

- 1st choice Beta blockers (e.g. IV esmolol 0.5 mg/kg over 1 minute, followed by a 50 mcg/kg/minute infusion) or PO carvedilol or digitalis or combine both. If persistent use amiodarone - anticoagulation (e.g. enoxaparin 1mg/kg sc stat) - If unstable: cardioversion - Refer to atrial fibrillation resident survival guide

- Hydral-nitrates (also useful in African American patients) - Avoid combining ACEIs, ARBs, aldosterone blockers

- Refer to resident survival guide for sepsis or pulmonary embolus or otherwise.

- Clinical assessment classification

- Presence of congestion Poor perfusion (i.e. wet&cold)

- NO congestion Poor perfusion (i.e. dry&cold)

- Presence of congestion Normal perfusion (i.e. wet&warm)

- NO congestion Normal perfusion (i.e. dry&warm)

-Rapid intervention - CCU admission - Invasive hemodynamic monitoring (Central, arterial line, pulmonary catheter) - Intravenous inotropic drugs (e.g.dobutamine 2-20mcg/kg/min IV) - In countries where it is available, early levosimendan infusion can be considered ( SBP has to be >100 mm Hg) I.V.: Loading dose: 6-24 mcg/kg over 10 minutes followed by a continuous infusion of 0.05-0.2 mcg/kg/minute

- CCU admission - Intravenous inotropic drugs (e.g.dobutamine 2-20mcg/kg/min IV)

- Salt restriction - Continue GDMT while watching BP. - Early loop diuretics (e.g. furosemide 20-40mg IV stat, titrate dose considering (SBP, BUN/CR, Prior use) - Consider ultrafiltration for refractory congestion

- Continue GDMT - Continue evidence-based beta-blockers ( i.e., bisoprolol, carvedilol, and sustained release metoprolol succinate)

- 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.

- Persistent hyponatremia - Consider vasopressin antagonists (e.g. tolvaptan; start with 15mg orally daily)

- Consider discharge if clinically stable - Refer to multidisciplinary HF disease-management programs.

Do's

• 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.
• Make sure your patient is on DVT prophylaxis unless contraindicated.
• Make use of aldosterone receptor antagonists (i.e. spironolactone or eplerenone) in patients with NYHA class II-IV and who have LVEF of 35% or less, unless contraindicated, to reduce morbidity and mortality. Patients with NYHA class II should have a history of prior cardiovascular hospitalization or elevated plasma natriuretic peptide levels to be considered for aldosterone receptor antagonists. Creatinine should be 2.5 mg/dL or less in men or 2.0 mg/dL or less in women (or estimated glomerular filtration rate >30 mL/min/1.73 m2), and potassium should be less than 5.0 mEq/L. Careful monitoring of potassium, renal function, and diuretic dosing should be performed at initiation and closely followed thereafter to minimize risk of hyperkalemia and renal insufficiency.
• Start hydralazine and isosorbide dinitrate to reduce morbidity or mortality in patients with current or prior symptomatic HFrEF who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency, unless contraindicated. This combination has proven beneficial in African American population as well.
• Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.
• Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
• Use a combination of hydralazine and isosorbide dinitrate. They have been proven to reduce morbidity or mortality in patients with current or prior symptomatic HFrEF who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency, unless contraindicated.
• Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .

Don'ts

• If possible, don't order NSAIDs, sympathomimetics, tricyclic antidepressants, class I and III antiarrhythmics (except amiodarone), and nondihydropyridine calcium channel blockers as they can cause harm in acute decompensated HF.
• Don't Use parenteral inotropes in normotensive patients with acute decompensated HF without evidence of decreased organ perfusion.
• Don't combine an ACEI, ARB, and aldosterone antagonist in patients with HFrEF unless otherwise indicated as this combination carries a risk of renal functions worsening and hyperkalemia.
• Don't use aldosterone receptor antagonists in patients with hyperkalemia or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.
• Don't continue nutritional supplements with no proven benefit.
• Don't use statins routinely without other indications.

References

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