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]

Acute decompensated heart failure Resident Survival Guide Microchapters
Overview
Classification
Causes
Diagnosis
Treatment Stage A Stage B Stage C Stage D Diuretic Therapy Medications
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 (also known as acute decompensated heart failure, flash pulmonary edema, ADHF). 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, BNP. The management therapies aim at achieving symptomatic relief (oxygen, diuresis, morphine) and reducing morbidity and mortality (ACE inhibitors or (ARBs), beta blockers, aldosterone antagonists, and hydralazine/nitrate medications).

Classification

Based on the Stage of Congestive Heart Failure

ACCF/AHA Stages	Description
A	At high risk for 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 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)

• Heart failure with preserved ejection fraction (HFpEF) - This is an ejection fraction ≥ 50%.
• Heart failure with reduced ejection fraction (HFrEF) - This is an ejection fraction of ≤ 40%.

Causes

Life Threatening Causes

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

• Accelerated hypertension
• Acute kidney injury
• Acute myocardial ischemia
• Aortic dissection
• Diabetic ketoacidosis
• Myopericarditis
• Pulmonary embolus
• Severe anemia
• Systemic inflammatory response syndrome
• Thyrotoxicosis
• Valvular heart disease
• Ventricular arrhythmias

Common Causes

• Acute coronary syndrome
• Acute kidney injury
• Acute severe myocarditis
• Cardiac arrhythmias
• Cardiomyopathy
• Cardiotoxic agents - alcohol, cocaine
• Decompensation of an underlying chronic heart failure
• Hypertensive crisis
• Pulmonary embolus
• Systemic Inflammatory response syndrome
• Valvular heart disease

Diagnosis

Characterize the symptoms: Symptoms of fluid accumulation ❑ Dyspnea at rest ❑ At rest ❑ Exertional ❑ Paroxysmal nocturnal dyspnea ❑ Orthopnea ❑ Cough ❑ Peripheral edema Symptoms of reduced cardiac output: ❑ Fatigue ❑ Oliguria ❑ Dizziness ❑ Cyanosis ❑ Altered mental status ❑ Cyanosis ❑ Abdominal pain ❑ Ascites 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 medications ❑ Intake of cardiotoxic medications ❑ 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 ❑ Often in respiratory distress ❑ Often sitted in an upright position Vitals: ❑ Temperature ❑ Fever, suggestive of underlying infection ❑ Pulse ❑ Tachycardia ❑ Narrow pulse pressure (<25 mmHg) ❑ Blood pressure ❑ Hypotension, suggestive of circulatory collapse ❑ Hypertension, ❑ Respiration ❑ Dyspnea, commonest symptom ❑ Wheeze, suggestive of cardiac asthma ❑ Pulse oximetry ❑ Weight ❑ Subtract 'dry weight' from value to assess edema Skin ❑ Cool and clammy, in hypoperfusion or cardiogenic shock ❑ Cyanosis, in severe hypoxemia ❑ Anasarca Neck examination: ❑ Jugular vein distention ❑ Central venous pressure > 16 cm H2O ❑ Hepatojugular reflux Respiratory examination ❑ Tachypnea ❑ Dullness at lung bases, suggestive of pleural effusion ❑ Crackles/crepitations/rales Cardiovascular examination: ❑ Displaced apex beat, suggestive of enlarged left ventricle ❑ Parasternal heave, when right ventricular pressure is increased ❑ S3 or S4 or both ❑ Gallops ❑ New or changed murmur, suggesting underlying valvular heart diseases ❑ mitral regurgitation - holosystolic murmur ❑ Aortic regurgitation ❑ Aortic stenosis 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 ❑ Troponin ❑ Electrolytes ❑ Hyponatremia, suggestive of ❑ ❑ ❑ ❑ 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, Class I, level of evidence A) ❑ Chest x ray (Class I, level of evidence C) ❑ Cardiomegaly ❑ Cardiogenic Pulmonary edema ❑ Kerley B lines Short parallel lines at the lung periphery suggestive of pulmonary congestion ❑ Peribronchial cuffing The red arrows point to thickened bronchial walls that have a doughnut-like appearance. ❑ Cephalization This refers to the redistribution of blood into the upper lobe vessels ❑ EKG (Class I, level of evidence C) ❑ Evidence of ischemia ❑ Infarction ❑ Arrythmia ❑ Left ventricular hypertrophy ❑ 2-D echocardiography with doppler (Class I, level of evidence C) ❑ Ventricular size, function, wall thickness, wall motion, and valve function Additional tests to rule out other etiologies: ❑ 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 alternative diagnoses: ❑ Acute asthma ❑ Acute respiratory distress syndrome ❑ Cardiac tamponade ❑ Pneumonia ❑ Pulmonary embolism

Determine the stage of heart failure using the ACCF/AHA

At high risk for heart failure ❑ Patients with: ❑ HTN, DM, obesity, CAD, metabolic syndrome ❑ Family history of cardiomyopathy ❑ Patients using cardiotoxins No structural heart disease No symptoms of heart failure

Patients with structural heart disease ❑ Previous MI ❑ LV remodelling - LVH + low EF ❑ Family history of cardiomyopathy ❑ Asymptomatic valvular disease No sign or symptom of heart failure

Patients with structural heart disease No sign or symptom of heart failure

Refractory heart failure ❑ Marked symptoms at rest ❑ Recurrent hospitalizations

Stage A

Stage B

Stage C

Stage D

Treatment

Stage A

Treatment goals: ❑ Promote healthy lifestyle ❑ Prevent CAD and comorbidities ❑ Prevent LV structural abnormalities
❑ 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

Stage B

Treatment goal: ❑ Prevent symptoms of heart failure
❑ 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%

Stage C

Initial stabilization: ❑ Assess airway ❑ Nurse 45 degrees upright ❑ 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: ❑ 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 - systolic blood pressure < 80 - 90 mm Hg ❑ Admit ICU or CCU for closer monitoring ❑ Continue oxygen therapy ❑ For SBP 85 - 100 mm Hg ❑ Consider dobutamine or milrinone ❑ For SBP < 85 mm Hg ❑ Consider dopamine and norepinephrine ❑ Intra-aortic balloon pump, if hypotension persists ❑ Click here for more information regarding cardiogenic shock.

Treat precipitating causes/co-morbidities ❑ Acute aortic/mitral regurgitation ❑ Acute coronary syndrome ❑ Anemia ❑ Aortic dissection ❑ Atrial fibrillation ❑ Hypertensive crisis ❑ Renal failure ❑ Sepsis

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

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 inbibitors or (ARBs) if LVEF is ≤ 40% ❑ Beta blockers ❑ 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 BP, volume status, congestion, oxygenation ❑ Daily weights ❑ Intake and output charts ❑ Convert all IV diuretic to oral ❑ Continue or initiate ❑ ACE inhibitors ❑ Beta blockers ❑ Omega-3 fatty acid ❑ 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)

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

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.
	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 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 (diltiazem, verapamil 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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