Heart failure resident survival guide

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For acute heart failure prevention click here.

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

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

Overview

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

Classification

Based on the Severity of Congestive Heart Failure

The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:

NYHA
classification
Description
I No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
II Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
III Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
IV Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest

NYHA - New York Heart Association

Based on the Stage of Heart Failure

ACCF/AHA Stages Description
A At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
B Structural heart disease but without signs or symptoms of HF
C Structural heart disease with prior or current symptoms of HF
D Refractory HF requiring specialized interventions

ACCF - American College of Cardiology Foundation; AHA - American Heart Association

Based on Left Ventricular Ejection Fraction (LVEF)

Causes

Life Threatening Causes

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

Common Causes

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

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

Boxes in red signify that an urgent management is needed.

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

 
 
Identify cardinal findings that increase the pretest probability of acute heart failure

❑ Past medical history of heart failure
❑ History of orthopnea and paroxysmal nocturnal dyspnea
Dyspnea
Chest pain
❑ Pulmonary crepitations/rales/crackles
Cool extremities
Peripheral edema

Third heart sound (S3)
 
 
 
 
 
 
 
 
 
Does the patient have any of the following findings that require urgent management?

Hypotension (SBP < 90 mmHg or drop in MAP >30 mmHg)
Altered mental status
Cold and clammy extremities
Urine output <0.5mL/kg/hr

Metabolic acidosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
Treat cardiogenic shock

❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring
❑ Initiate oxygen therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa)[1]

❑ Non-rebreather face masks
Continuous positive airway pressure (CPAP) or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks
❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails

❑ For SBP 85 - 100 mm Hg

❑ Consider dobutamine at 2.5 to 5 mcg/kg/min or milrinone at 0.125 to 0.75 mcg/kg/min

❑ For SBP < 85 mm Hg

❑ Consider dopamine at 5 to 10 mcg/kg/min and norepinephrine at 0.2–1.0 mcg/kg/min

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

Click here for cardiogenic shock resident survival guide
 
Does the patient have severe symptoms of heart failure?

NYHA class III

❑ Marked limitation of physical activity
❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF

NYHA class IV

❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[2][3]

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


 
 
 
 
 
 
 
Characterize the symptoms:

Symptoms of fluid accumulation
Dyspnea

❑ At rest
❑ Exertional

Paroxysmal nocturnal dyspnea
Orthopnea
Cough
Peripheral edema
Ascites
Symptoms of reduced cardiac output
Fatigue
Oliguria
Dizziness
Syncope
Altered mental status
Cyanosis
Abdominal pain (suggestive of mesenteric ischemia)
Symptoms suggestive of precipitating events
Chest pain (if myocardial ischemia is present)
Palpitations (suggestive of arrhythmias)
Fever (suggestive of sepsis)
Nonspecific symptoms
Anorexia
Bloating
Nausea
Weight loss


Obtain a detailed history:
Past medical history

Atrial fibrillation
Cardiomyopathy
Diabetes mellitus
Hypertension
Myocarditis
Previous myocardial infarction
Prior heart failure
Sleep apnea
Thyroid disease
Valvular heart disease

Medication history

❑ Noncompliance with previously prescribed medications for heart failure
❑ Intake of the following drugs:
Alcohol
Beta blockers
Calcium channel blockers like verapamil which can exacerbate CHF or diltiazem which can cause peripheral edema
Chemotherapy drugs - anthracyclines
NSAIDs which should not be given in CHF
Thiazolidinedione

Family history

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

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

Vitals:
Temperature

Fever (suggestive of underlying infection)

Pulse

Tachycardia
Narrow pulse pressure (<25 mmHg)

Blood pressure

Hypotension (suggestive of circulatory collapse)
Hypertension

Respiration

Tachypnea (commonest symptom)

Pulse oximetry assure sat is > 90%

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

Skin
Cool and clammy, in hypoperfusion or cardiogenic shock
Cyanosis, in severe hypoxemia
Anasarca
Neck examination:
Jugular vein distention is often present

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

Cardiovascular examination
❑ Displaced apex beat (suggestive of enlarged left ventricle)
Parasternal heave (suggestive of elevated right ventricular pressure)
S3 (typical) or S4 or both
❑ New or changed murmur (suggestive of an underlying valvular heart diseases)

Mitral regurgitation - Holosystolic murmur
Aortic regurgitation - Decrescendo diastolic murmur
Aortic stenosis - Crescendo-decrescendo systolic ejection murmur with ejection click

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

Extremity examination
Pedal edema

Neurological examination
Altered mental status

Syncope (suggestive of aortic stenosis or pulmonary embolism)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order tests:

Routine (Class I, level of evidence C)

CBC (rule out anemia)
Troponin
❑ Elevated in myocardial ischemia and acute cardiogenic pulmonary edema, particularly if creatinine clearance (CrCl) is reduced
Troponin T ≥0.1 ng/mL (associated with poor survival)[4]
Electrolytes
❑ Dilutional hyponatremia (with the presence of edema)
Serum calcium
Serum magnesium which can be lowered by diuresis
Serum bicarbonate to monitor contraction alkalosis with diuresis
BUN, creatinine may be elevated due to poor renal perfusion
Urinalysis
Fasting blood sugar
Fasting lipid profile
Liver function tests
TSH

BNP or NT-pro BNP (if diagnosis is uncertain)
Heart failure is unlikely if:[1][5]

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

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

Cardiomegaly (cardiothoracic ratio >50%)
❑ Cardiogenic pulmonary edema
Kerley B lines
Peribronchial cuffing
Cephalization
Chest X-ray findings in a patient with acute heart failure

EKG

Low QRS voltage due to electrically inert myocardium
Arrhythmia (usually atrial fibrillation which carries a poor prognosis and requires slowing to improve filling & cardiac output)
Poor R wave progression (suggestive of a prior MI)
Left ventricular hypertrophy (consistent with a history of hypertension)
Left bundle branch block (LBBB) due to prior MI, may result in dysynchrony
Left atrial enlargement
due to valvular disease or hypertension
❑ Non-specific ST segment and T wave changes may suggest ischemia

❑ 2-D echocardiography with Doppler
(Class I, level of evidence C)

❑ Assess ventricular size, function, wall thickness, wall motion, and valve function

Radionuclide ventriculography or MRI

❑ To assess LVEF and volume when echocardiography is inadequate
❑ To assess myocardial infiltrative processes or scar burden (MRI)

Coronary angiography (in settings of ischemia)
Pulmonary artery catheterization in respiratory distress or shock or to definitively assess volume status and tailor therapy


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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnoses:

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

Patients with structural heart disease
This refers to patients with the following:

❑ Previous MI
❑ LV remodeling* (including LVH + low EF)
❑ Asymptomatic valvular disease

AND

Signs or symptoms of heart failure

LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury
 
Stage D

Refractory heart failure

❑ Marked symptoms at rest
❑ Recurrent hospitalizations
 
 
 

Treatment

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

 
 
 
 
 
 
 
Initial stabilization:

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

❑ Give oxygen by:
❑ Non-rebreather face masks
Continuous positive airway pressure
❑ Avoid IV morphine - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though

❑ Ensure continuous cardiac monitoring
❑ Secure intravenous access with 18 gauge canula
❑ Monitor vitals signs
❑ Monitor fluid intake and urine output

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider admission if the following is present:[6]

Hypotension and/or cardiogenic shock
❑ Poor end-organ perfusion - worsening renal function, cold clammy extremities, altered mental status
Hypoxemia - Sa02 ↓90%
Atrial fibrillation with a rapid ventricular response resulting in hypotension

❑ Presence of an acute coronary syndrome
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat precipitating causes/co-morbidities
Click for detailed management

Atrial fibrillation
Atrial fibrillation and acute decompensated heart failure are intimately related; the successful management of atrial fibrillation is often critical to the success of reversing the acute decompensation.
Points to note:
❑ Rate control of atrial fibrillation is the mainstay of arrhythmia therapy.

❑ IV diltiazem (has no negative inotropic effect) at a loading dose of 0.25 mg/kg over 2 min and maintenance dose of 5 to 15 mg/h
❑ IV short acting esmolol at a loading dose of 500 mcg/kg over 1 min and maintenance dose at 60 to 200 mcg/kg/min

Avoid the use of drugs with negative inotropic effects such as beta blockers and non-dihydropyridine calcium channel blockers e.g., verapamil in the treatment of acute decompensated systolic heart failure
❑ Consider cardioversion

❑ If the patient is in cardiogenic shock
❑ If new onset atrial fibrillation is the clear precipitant of the hemodynamic decompensation

Note: Unfractionated heparin should be administered before cardioversion
Acute aortic/mitral regurgitation
Acute coronary syndrome
Anemia
Aortic dissection
Hypertensive crisis
Renal failure

Sepsis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess hemodynamic and volume status[7]

Congestion at rest (dry vs. wet)
"Wet" suggested by orthopnea, ↑JVP, rales, S3, pedal edema

❑ Low perfusion at rest (warm vs. cold)
"Cold" suggested by narrow pulse pressure, cool extremities, hypotension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Classify the patient based on the
left ventricular ejection fraction
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diastolic heart failure
LVEF ≥ 50%
 
Systolic heart failure
LVEF ≤ 40%
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment

❑ Rate control - to prolong left ventricular filling time

❑ Administer beta blockers, especially in the setting of atrial fibrillation

Diuretic therapy to reduce volume overload (click for details)
Avoid excess diuresis in patients with diastolic heart failure as they are prone to hypotension due to reductions in preload
❑ Relief of ischemia

Coronary revascularization in the setting of angina and demonstrable myocardial ischemia
The use of inotropes such as dobutamine, milrinone is not indicated
 
Treatment

Consider the following:
Diuretic therapy (click for details)
❑ IV vasodilators
❑ Inotropic therapy
❑ Vasopressor support
ACE inhibitors
ACE inhibitor should not be initiated within the first 12 to 24 hours of acute decompensation of heart failure as these agents may result in prolonged hypotension and impaired end organ perfusion
It can be continued in:

❑ Hemodynamically stable patients with acute decompensated heart failure without a rising creatinine or hyperkalemia

Beta blockers[8]
Beta blockers should not be initiated during acute decompensated heart failure
It can be continued in:

❑ A patient chronically on beta blockers in the absence of hypotension

Aldosterone antagonists
It can be continued in:

❑ A patients chronically on aldosterone antagonists prior to the development of acute decompensated heart failure in the absence of hypotension, hyperkalemia, and impaired renal function
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Indications for implantable cardioverter defibrillator (ICD)

❑ As primary prevention of sudden cardiac death in:

❑ Post MI with LVEF ≤ 35%, NYHA II or III on chronic GDMT (Class I, level of evidence A)
❑ Post MI with LVEF ≤ 30%, NYHA I on chronic GDMT (Class I, level of evidence B)
❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III

Contraindications
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year
❑ Incessant ventricular tachycardia or ventricular fibrillation
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or cardiac resynchronization therapy

Ventricular tachycardia due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Indications for cardiac transplantation

❑ Refractory cardiogenic shock
❑ Documented dependence on intravenous inotropic support to maintain adequate organ perfusion
❑ Peak VO2 less than 10 mL/kg per min with achievement of anaerobic metabolism

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
General measures

Low sodium diet
❑ Monitor blood pressure, congestion, oxygenation
❑ Daily weights using same scale after 1st void at same time of day
❑ Intake and output charts
❑ Convert all IV diuretic to oral forms in anticipation of discharge
Continue or initiate prior to discharge

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

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

❑ Encourage physical activity in stable patients
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Discharge and follow-Up

❑ Patient and family education
❑ Prior to discharge, ensure:

❑ Low salt diet
❑ Oral medication plan is stable for 24 hours
❑ No IV vasodilator or inotropic drugs for 24 hours
❑ Weighing scale is present in patient's home
Smoking cessation counseling
❑ Follow-up clinic visit scheduled within 7 to 10 days
❑ Ambulation prior to discharge to assess functional capacity

❑ Telephone follow-up call usually 3 days post discharge
❑ Potassium monitoring and repletion

Click here for the detailed management of hyperkalemia and hypokalemia
 


Diuretic Therapy Details

 
 
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
❑ Initiate IV diuretics due to poor absorption from gut

Frusemide 40 mg, or
Torsemide 20 mg, or
Bumetanide 1 mg

Contraindications to IV Diuresis
Hypotension and cardiogenic shock

Note - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)

 
 
 
 
 
 
 
 
 
 
 
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
Indications:
❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women
❑ Estimated glomerular filtration rate >30 mL/min/1.73 m2
Serum potassium ≤ 5.0 mEq/L
❑ NYHA class II–IV HF with LVEF ≤ 35%

K+- sparing diuretic e.g amiloride or triamterene should not be administered with aldosterone antagonist given the risk of hyperkalemia
 
Adjuvants to diuretics

❑ Low dose dopamine to preserve renal function and renal blood flow
❑ IV nitroprusside, nitroglycerin, or nesiritide for hemodynamically stable patients to relieve dyspnea

❑ Vasopressin antagonists (e.g. tolvaptan; start with 15mg orally daily) [10] [11]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No symptomatic improvement
(refractory edema)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ultrafiltration or dialysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
General measures

❑ Monitor BP, volume status, congestion
❑ Daily weights
❑ Intake and output charts

❑ Convert all IV diuretic to oral
❑ Daily serum electrolytes, urea & creatinine
DVT prophylaxis
 

Medications

Drug Class Drug Daily dose Maximum daily dose
Loop diuretics Furosemide 20 to 40 mg once or twice
In HF patients on loop diuretic, the initial IV dose should
be greater or equal to their chronic oral daily dose.[12]
600 mg
Bumetanide 0.5 to 1.0 mg once or twice 10 mg
Torsemide 10 to 20 mg once 200 mg
Thiazide diuretics Chlorothiazide 250 to 500 mg once or twice 1000 mg
Hydrochlorothiazide 25 mg once or twice 200 mg
Metolazone 2.5 mg once 20 mg
K+- sparing diuretic Amiloride 5 mg once 20 mg
Spironolactone 12.5 to 25.0 mg once 50 mg
Triamterene 50 to 75 mg twice 200 mg
ACE inhibitors Enalapril 2.5 mg twice 10 to 20 mg twice
Lisinopril 2.5 to 5 mg once 20 to 40 mg once
Ramipril 1.25 to 2.5 mg once 10 mg once
ARBs Candesartan 4 to 8 mg once 32 mg once
Losartan 25 to 50 mg once, 50 to 150 mg once
Valsartan 20 to 40 mg twice 160 mg twice
Beta blockers Bisoprolol 1.25 mg once 10 mg once
Carvedilol 3.125 mg twice 50 mg twice
Metoprolol succinate 12.5 to 25.0 mg once 200 mg once
Aldosterone antagonists Spironolactone 12.5 to 25.0 mg once 25 mg once or twice
Eplerenone 25 mg once 50 mg once
Inotropes Dopamine 5 to 10 mcg/kg/min
Dobutamine 2.5 to 5 mcg/kg/min
Milrinone 0.125 to 0.75 mcg/kg/min
Vasodilators Nitroglycerin 5 to 10 mcg/min, increase dose by 5-10mcg/min
every 3-5 mins as tolerated
Max is 400mcg/min
Nitroprusside 5 to 10 mcg/min, increase dose by 5-10mcg/min
every 5 mins as tolerated
Max is 400mcg/min
Nesiritide 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion Max of 0.03 mcg/kg/minute
Hydralazine and isosorbide dinitrate Fixed-dose combination 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily,
75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
Individual doses Hydralazine: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses
Isosorbide dinitrate: 20 to 30 mg 3 or 4 times daily
120 mg daily in divided doses
Digoxin 0.125 to 0.25 mg daily. There is no need for a loading dose in CHF.
Drugs that increase the concentration of digoxin include amiodarone, quinidine and verapamil

Do's

  • Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of heart failure as defined by ACCF/AHA. These are primarily the class 1 recommendations. It involves the use of ACE inhibitors or (ARBs), beta blockers, aldosterone antagonists, and hydralazine/nitrate medications.
  • Order an echocardiogram as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
  • Digoxin decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include amiodarone, quinidine and verapamil. [13][14][15][16][17][18][19]
  • DVT prophylaxis unless contraindicated.[20][21]
  • Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.[22][23]
  • Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
  • Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .[24][25]

Don'ts

References

  1. 1.0 1.1 McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K; et al. (2012). "ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC". Eur Heart J. 33 (14): 1787–847. doi:10.1093/eurheartj/ehs104. PMID 22611136.
  2. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH; et al. (2013). "2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines". Circulation. 128 (16): 1810–52. doi:10.1161/CIR.0b013e31829e8807. PMID 23741057.
  3. Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG; et al. (2009). "2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation". J Am Coll Cardiol. 53 (15): e1–e90. doi:10.1016/j.jacc.2008.11.013. PMID 19358937.
  4. Perna, ER.; Macín, SM.; Parras, JI.; Pantich, R.; Farías, EF.; Badaracco, JR.; Jantus, E.; Medina, F.; Brizuela, M. (2002). "Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema". Am Heart J. 143 (5): 814–20. PMID 12040342. Unknown parameter |month= ignored (help)
  5. Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A; et al. (2006). "The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure". Br J Gen Pract. 56 (526): 327–33. PMC 1837840. PMID 16638247.
  6. Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN (2010). "HFSA 2010 Comprehensive Heart Failure Practice Guideline". Journal of Cardiac Failure. 16 (6): e1–194. doi:10.1016/j.cardfail.2010.04.004. PMID 20610207. Retrieved 2013-04-29. Unknown parameter |month= ignored (help)
  7. Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH; et al. (2003). "Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure". J Am Coll Cardiol. 41 (10): 1797–804. PMID 12767667.
  8. Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA (2007). "Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET". European Journal of Heart Failure. 9 (9): 901–9. doi:10.1016/j.ejheart.2007.05.011. PMID 17581778. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  9. Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG; et al. (2008). "Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial". Lancet. 372 (9645): 1223–30. doi:10.1016/S0140-6736(08)61239-8. PMID 18757090. Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11
  10. Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A; et al. (2004). "Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial". JAMA. 291 (16): 1963–71. doi:10.1001/jama.291.16.1963. PMID 15113814.
  11. Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I; et al. (2001). "Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure". Circulation. 104 (20): 2417–23. PMID 11705818.
  12. Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E, O'Connor CM (2011). "Diuretic strategies in patients with acute decompensated heart failure". The New England Journal of Medicine. 364 (9): 797–805. doi:10.1056/NEJMoa1005419. PMC 3412356. PMID 21366472. Retrieved 2013-04-30. Unknown parameter |month= ignored (help)
  13. The Captopril-Digoxin Multicenter Research Group. Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. JAMA. 1988;259:539–44.
  14. Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52
  15. Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med. 1982;306: 699–705.
  16. Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.
  17. . DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med. 1989;320:677–83.
  18. Uretsky BF, Young JB, Shahidi FE, et al., for the PROVED Investigative Group. Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. J Am Coll Cardiol. 1993;22:955–62.
  19. Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.
  20. Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A; et al. (2003). "Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study". Blood Coagul Fibrinolysis. 14 (4): 341–6. PMID 12945875.
  21. Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel (2012). "Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): 7S–47S. doi:10.1378/chest.1412S3. PMC 3278060. PMID 22315257.
  22. Grosskopf I, Rabinovitz M, Rosenfeld JB (1986). "Combination of furosemide and metolazone in the treatment of severe congestive heart failure". Isr J Med Sci. 22 (11): 787–90. PMID 3793436.
  23. Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR (2005). "Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature". Cardiovasc Drugs Ther. 19 (4): 301–6. doi:10.1007/s10557-005-3350-2. PMID 16189620.
  24. Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI (2000). "Predictors of readmission among elderly survivors of admission with heart failure". Am Heart J. 139 (1 Pt 1): 72–7. PMID 10618565.
  25. Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW; et al. (2010). "Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure". JAMA. 303 (17): 1716–22. doi:10.1001/jama.2010.533. PMID 20442387.
  26. Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.
  27. . Herchuelz A, Derenne F, Deger F, et al. Interaction between nonsteroidal anti-inflammatory drugs and loop diuretics: modulation by sodiumbalance. J Pharmacol Exp Ther. 1989;248:1175–81.
  28. Gottlieb SS, Robinson S, Krichten CM, et al. Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1992;70:890–3
  29. Bank AJ, Kubo SH, Rector TS, et al. Local forearm vasodilation with intra-arterial administration of enalaprilat in humans. Clin Pharmacol Ther. 1991;50:314–21.
  30. The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12.
  31. The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med. 1992;327:227–33.
  32. Pratt CM, Eaton T, Francis M, et al. The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-benefit ratio. Am Heart J. 1989;118:433–40.
  33. Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M (2002). "Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial". JAMA : the Journal of the American Medical Association. 287 (12): 1541–7. PMID 11911756. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  34. Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A; et al. (2004). "Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study". N Engl J Med. 351 (6): 543–51. doi:10.1056/NEJMoa040135. PMID 15295047.
  35. Bozkurt B, Agoston I, Knowlton AA (2003). "Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines". J Am Coll Cardiol. 41 (2): 211–4. PMID 12535810.
  36. Horwich TB, MacLellan WR, Fonarow GC (2004). "Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure". J Am Coll Cardiol. 43 (4): 642–8. doi:10.1016/j.jacc.2003.07.049. PMID 14975476.
  37. Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG; et al. (2008). "Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial". Lancet. 372 (9645): 1231–9. doi:10.1016/S0140-6736(08)61240-4. PMID 18757089.


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