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Chronic Heart Failure

HF

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

ʍ3
 
 
 
 
 
 
 
 
- 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[2][3][4][5][6][7]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
- Non-invasive monitoring (SaO2, BP, temperature)+ Oxygen therapy
- IV furosemide 20-40mg stat, may repeat dose based on clinical response, BP, prior diuretic use [8][9][10]
- NIPPV (e.g. CPAP) if dyspnea not improved[11][12]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
- 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.) [8]
 
 
 
 
- 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"[13][14]
 
 
- 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.[15] If persistent use amiodarone
- anticoagulation[16][17] (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)[18][19][20][21][22]
- Avoid combining ACEIs, ARBs, aldosterone blockers
 
 
- Refer to resident survival guide for sepsis or pulmonary embolus or otherwise.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
- Clinical assessment classification[23]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
- 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 [24]
 
- 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) [8][10][9]
- Consider ultrafiltration for refractory congestion[25]
 
 
 
 
 
- Continue GDMT[26][27][28]
- Continue evidence-based beta-blockers ( i.e., bisoprolol, carvedilol, and sustained release metoprolol succinate)[29]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
- 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) [30] [31]
 
 
 
 
 
- Consider discharge if clinically stable
- Refer to multidisciplinary HF disease-management programs.[32][33][34]

Table

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%.
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 inhibitors or (ARBs), beta blockers, aldosterone antagonists, and hydralazine/nitrate medications.


References

  1. ↑ Yancy CW, Jessup M, Bozkurt B, Masoudi FA, Butler J, McBride PE; et al. (2013). "2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. doi:10.1016/j.jacc.2013.05.019. PMID 23747642.
  2. ↑ Januzzi JL, Sakhuja R, O'donoghue M, Baggish AL, Anwaruddin S, Chae CU; et al. (2006). "Utility of amino-terminal pro-brain natriuretic peptide testing for prediction of 1-year mortality in patients with dyspnea treated in the emergency department". Arch Intern Med. 166 (3): 315–20. doi:10.1001/archinte.166.3.315. PMID 16476871.
  3. ↑ Dao Q, Krishnaswamy P, Kazanegra R, Harrison A, Amirnovin R, Lenert L; et al. (2001). "Utility of B-type natriuretic peptide in the diagnosis of congestive heart failure in an urgent-care setting". J Am Coll Cardiol. 37 (2): 379–85. PMID 11216950.
  4. ↑ Mueller C, Scholer A, Laule-Kilian K, Martina B, Schindler C, Buser P; et al. (2004). "Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea". N Engl J Med. 350 (7): 647–54. doi:10.1056/NEJMoa031681. PMID 14960741. Review in: ACP J Club. 2004 Sep-Oct;141(2):35
  5. ↑ van Kimmenade RR, Pinto YM, Bayes-Genis A, Lainchbury JG, Richards AM, Januzzi JL (2006). "Usefulness of intermediate amino-terminal pro-brain natriuretic peptide concentrations for diagnosis and prognosis of acute heart failure". Am J Cardiol. 98 (3): 386–90. doi:10.1016/j.amjcard.2006.02.043. PMID 16860029.
  6. ↑ Bettencourt P, Azevedo A, Pimenta J, Friões F, Ferreira S, Ferreira A (2004). "N-terminal-pro-brain natriuretic peptide predicts outcome after hospital discharge in heart failure patients". Circulation. 110 (15): 2168–74. doi:10.1161/01.CIR.0000144310.04433.BE. PMID 15451800.
  7. ↑ Lee DS, Stitt A, Austin PC, Stukel TA, Schull MJ, Chong A; et al. (2012). "Prediction of heart failure mortality in emergent care: a cohort study". Ann Intern Med. 156 (11): 767–75, W-261, W-262. doi:10.7326/0003-4819-156-11-201206050-00003. PMID 22665814.
  8. ↑ 8.0 8.1 8.2 Mebazaa A, Gheorghiade M, Piña IL, Harjola VP, Hollenberg SM, Follath F, Rhodes A, Plaisance P, Roland E, Nieminen M, Komajda M, Parkhomenko A, Masip J, Zannad F, Filippatos G (2008). "Practical recommendations for prehospital and early in-hospital management of patients presenting with acute heart failure syndromes". Critical Care Medicine. 36 (1 Suppl): S129–39. doi:10.1097/01.CCM.0000296274.51933.4C. PMID 18158472. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  9. ↑ 9.0 9.1 Silvers SM, Howell JM, Kosowsky JM, Rokos IC, Jagoda AS (2007). "Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with acute heart failure syndromes". Annals of Emergency Medicine. 49 (5): 627–69. doi:10.1016/j.annemergmed.2006.10.024. PMID 17408803. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  10. ↑ 10.0 10.1 Costanzo MR, Johannes RS, Pine M, Gupta V, Saltzberg M, Hay J, Yancy CW, Fonarow GC (2007). "The safety of intravenous diuretics alone versus diuretics plus parenteral vasoactive therapies in hospitalized patients with acutely decompensated heart failure: a propensity score and instrumental variable analysis using the Acutely Decompensated Heart Failure National Registry (ADHERE) database". American Heart Journal. 154 (2): 267–77. doi:10.1016/j.ahj.2007.04.033. PMID 17643575. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  11. ↑ Masip J, Roque M, Sánchez B, Fernández R, Subirana M, Expósito JA (2005). "Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and meta-analysis". JAMA. 294 (24): 3124–30. doi:10.1001/jama.294.24.3124. PMID 16380593.
  12. ↑ {{cite journal| author=Peter JV, Moran JL, Phillips-Hughes J, Graham P, Bersten AD| title=Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis. | journal=Lancet | year= 2006 | volume= 367 | issue= 9517 | pages= 1155-63 | pmid=16616558 | doi=10.1016/S0140-6736(06)68506-1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16616558
  13. ↑ Fonarow GC, Adams KF, Abraham WT, Yancy CW, Boscardin WJ, ADHERE Scientific Advisory Committee, Study Group, and Investigators (2005). "Risk stratification for in-hospital mortality in acutely decompensated heart failure: classification and regression tree analysis". JAMA. 293 (5): 572–80. doi:10.1001/jama.293.5.572. PMID 15687312. Review in: ACP J Club. 2005 Jul-Aug;143(1):25
  14. ↑ Aronson D, Mittleman MA, Burger AJ (2004). "Elevated blood urea nitrogen level as a predictor of mortality in patients admitted for decompensated heart failure". Am J Med. 116 (7): 466–73. doi:10.1016/j.amjmed.2003.11.014. PMID 15047036.
  15. ↑ Khand AU, Rankin AC, Martin W, Taylor J, Gemmell I, Cleland JG (2003). "Carvedilol alone or in combination with digoxin for the management of atrial fibrillation in patients with heart failure?". J Am Coll Cardiol. 42 (11): 1944–51. PMID 14662257.
  16. ↑ Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M; et al. (2011). "Apixaban versus warfarin in patients with atrial fibrillation". N Engl J Med. 365 (11): 981–92. doi:10.1056/NEJMoa1107039. PMID 21870978. Review in: Ann Intern Med. 2012 Jan 17;156(2):JC1-2, JC1-3
  17. ↑ Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W; et al. (2011). "Rivaroxaban versus warfarin in nonvalvular atrial fibrillation". N Engl J Med. 365 (10): 883–91. doi:10.1056/NEJMoa1009638. PMID 21830957. Review in: Evid Based Med. 2012 Oct;17(5):148-9 Review in: Ann Intern Med. 2012 Jan 17;156(2):JC1-2, JC1-3
  18. ↑ Carson P, Ziesche S, Johnson G, et al., for the Vasodilator-Heart Failure Trial Study Group. Racial differences in response to therapy for heart failure: analysis of the vasodilator-heart failure trials. J Card Fail. 1999;5:178–87.
  19. ↑ Cohn JN. The Vasodilator-Heart Failure Trials (V-HeFT). Mechanistic data from the VA Cooperative Studies. Introduction. Circulation. 1993; 87:VI1–4.
  20. ↑ Carson P, Ziesche S, Johnson G, et al., for the Vasodilator-Heart Failure Trial Study Group. Racial differences in response to therapy for heart failure: analysis of the vasodilator-heart failure trials. J Card Fail. 1999;5:178–87.
  21. ↑ Cohn JN, Archibald DG, Ziesche S, et al. Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative Study. N Engl J Med. 1986;314:1547–52.
  22. ↑ Loeb HS, Johnson G, Henrick A, et al., for the V-HeFT VA Cooperative Studies Group. Effect of enalapril, hydralazine plus isosorbide dinitrate, and prazosin on hospitalization in patients with chronic congestive heart failure. Circulation. 1993;87:VI78–87.
  23. ↑ 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.
  24. ↑ Follath F, Cleland JG, Just H, Papp JG, Scholz H, Peuhkurinen K; et al. (2002). "Efficacy and safety of intravenous levosimendan compared with dobutamine in severe low-output heart failure (the LIDO study): a randomised double-blind trial". Lancet. 360 (9328): 196–202. PMID 12133653.
  25. ↑ Costanzo MR, Guglin ME, Saltzberg MT, Jessup ML, Bart BA, Teerlink JR, Jaski BE, Fang JC, Feller ED, Haas GJ, Anderson AS, Schollmeyer MP, Sobotka PA (2007). "Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure". Journal of the American College of Cardiology. 49 (6): 675–83. doi:10.1016/j.jacc.2006.07.073. PMID 17291932. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  26. ↑ pmid17581778">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)
  27. ↑ Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, O'Connor CM, Sun JL, Yancy CW, Young JB (2008). "Influence of beta-blocker continuation or withdrawal on outcomes in patients hospitalized with heart failure: findings from the OPTIMIZE-HF program". Journal of the American College of Cardiology. 52 (3): 190–9. doi:10.1016/j.jacc.2008.03.048. PMID 18617067. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  28. ↑ Butler J, Young JB, Abraham WT, Bourge RC, Adams KF, Clare R; et al. (2006). "Beta-blocker use and outcomes among hospitalized heart failure patients". J Am Coll Cardiol. 47 (12): 2462–9. doi:10.1016/j.jacc.2006.03.030. PMID 16781374.
  29. ↑ 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)
  30. ↑ 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.
  31. ↑ 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.
  32. ↑ McAlister FA, Stewart S, Ferrua S, McMurray JJ (2004). "Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials". J Am Coll Cardiol. 44 (4): 810–9. doi:10.1016/j.jacc.2004.05.055. PMID 15312864.
  33. ↑ Windham BG, Bennett RG, Gottlieb S (2003). "Care management interventions for older patients with congestive heart failure". Am J Manag Care. 9 (6): 447–59, quiz 460-1. PMID 12816174.
  34. ↑ {{cite journal| author=Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH et al.| title=Association between performance measures and clinical outcomes for patients hospitalized with heart failure. | journal=JAMA | year= 2007 | volume= 297 | issue= 1 | pages= 61-70 | pmid=17200476 | doi=10.1001/jama.297.1.61 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17200476
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