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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)

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

Monitoring

Discharge and follow-up

HF

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

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- 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.

Drugs

Drug Class	Drug	Daily doses, maximum daily dose
Loop diuretics	Furosemide	20 to 40 mg once or twice, 600 mg max daily dose IV dose should be 2.5 times the usual oral 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

Diuretic Therapy

Evidence of volume overload

❑ Low sodium diet (<2 g daily) ❑ Water restriction (<2L daily) in patients with hyponatremia ❑ 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 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)