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| _NOTOC__
| | #Redirect [[Heart failure resident survival guide]] |
| {{CMG}}; {{AE}} {{MS}} {{AO}}
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| ==Definitions==
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| {|class="wikitable"
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| ! !! Definition
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| | [[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.
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| | Heart failure with preserved ejection fraction (HFpEF)|| This is otherwise called [[Diastolic dysfunction|diastolic HF]]. It is characterized with an [[ejection fraction]] ≥ 50%.
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| | Heart failure with reduced ejection fraction (HFrEF)|| This is also called [[Systolic dysfunction|systolic HF]]. It is characterized with an [[ejection fraction]] of ≤ 40%.
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| | Refractory heart failure||
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| | 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 inhibitor]]s or ([[Angiotensin II receptor antagonist|ARBs]]), [[beta blocker]]s, [[aldosterone antagonist]]s, and [[hydralazine]]/[[Isosorbide dinitrate|nitrate]] medications.
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| |}
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| ====Goals of Therapy====
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| {|class="wikitable"
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| ! Goals!! Medications
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| | To alleviate symptoms||
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| | To reduce mortality||
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| | To reduce hospitalization||
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| | Treat underlying cardiovascular disease||
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| |}
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| ==Classifciation==
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| ====ACCF/AHA Stages of Heart Failure====
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| {|class="wikitable"
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| ! Stage of Heart Failure !! Description
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| | '''A'''|| At high risk for HF but without structural heart disease or symptoms of HF.
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| | '''B'''|| Structural heart disease but without signs or symptoms of HF.
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| | '''C'''|| Structural heart disease with prior or current symptoms of HF.
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| | '''D'''|| Refractory HF requiring specialized interventions.
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| |}
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| ''ACCF - American College of Cardiology Foundation; AHA - American Heart Association.''
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| ====New York Heart Association (NYHA)====
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| {|class="wikitable"
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| ! Stage of Heart Failure !! Description
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| | '''I'''|| No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF.
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| | '''II'''|| Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF.
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| | '''III'''|| Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF.
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| | '''IV'''|| Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest.
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| |}
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| ==Causes==
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| ===Life Threatening Causes===
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| 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.
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| * [[Accelerated hypertension]]
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| * [[Acute kidney injury]]
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| * [[Acute myocardial ischemia]]
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| * Acute or progressive valvular disease (e.g. acute [[mitral regurgitation]])
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| * [[Endocarditis|Acute or subacute valve disease endocarditis]]
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| * [[Aortic dissection]]
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| * Cardiac arrhythmias, especially [[ventricular arrhythmias]]
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| * Cardiotoxic agents (e.g. [[alcohol]], [[cocaine]], and certain [[chemotherapy]] drugs)
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| * Diabetic emergencies (e.g. [[ketoacidosis]])
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| * [[Myopericarditis]]
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| * [[Pulmonary embolus]]
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| * Severe [[anemia]] (e.g. acute [[hemolysis]] or [[blood loss]])
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| * [[Sepsis|Systemic Inflammatory response syndrome]]
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| * [[Thyrotoxicosis]]
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| ===Common Causes===
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| * [[Accelerated hypertension]]
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| * [[Acute kidney injury]]
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| * [[Acute myocardial ischemia]]
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| * Acute or progressive valvular disease (e.g. acute [[mitral regurgitation]])
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| * [[Cardiac arrhythmias]]
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| * Excessive [[alcohol]] or illicit drug use (e.g. [[cocaine]])
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| * [[Myocardial ischemia]] (e.g. [[AF]])
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| * [[Pulmonary embolus]]
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| * [[Sepsis|Systemic Inflammatory response syndrome]]
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| ==Management==
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| ====Commonly Prescribed Medications====
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| {| class="wikitable sortable"
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| ! Drug Class
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| ! Drug
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| ! Daily doses, maximum daily dose
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| | [[Loop diuretics]]||[[Furosemide]] ||20 to 40 mg once or twice, 600 mg max daily dose <br>In HF patients on loop diuretic, the initial IV dose should <br>be greater or equal to their chronic oral daily dose.<ref name="pmid21366472">{{cite journal |author=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 |title=Diuretic strategies in patients with acute decompensated heart failure |journal=[[The New England Journal of Medicine]] |volume=364 |issue=9 |pages=797–805 |year=2011 |month=March |pmid=21366472 |pmc=3412356 |doi=10.1056/NEJMoa1005419 |url=http://www.nejm.org/doi/abs/10.1056/NEJMoa1005419?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov |accessdate=2013-04-30}}</ref>
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| | || [[Bumetanide]] || 0.5 to 1.0 mg once or twice, 10 mg
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| | || [[Torsemide]]|| 10 to 20 mg once, 200 mg
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| | [[Thiazide diuretics]] || [[Chlorothiazide]] || 250 to 500 mg once or twice, 1000 mg
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| | || [[Hydrochlorothiazide]] || 25 mg once or twice, 200 mg
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| | || [[Metolazone]] || 2.5 mg once, 20 mg
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| | K<sup>+</sup>- sparing diuretic|| [[Amiloride]] || 5 mg once, 20 mg
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| | || [[Spironolactone]] || 12.5 to 25.0 mg once, 50 mg
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| | || [[Triamterene]] || 50 to 75 mg twice, 200 mg
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| |-
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| | [[ACE inhibitors]] || [[Enalapril]] || 2.5 mg twice, 10 to 20 mg twice
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| | || [[Lisinopril]] || 2.5 to 5 mg once, 20 to 40 mg once
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| | || [[Ramipril]] ||1.25 to 2.5 mg once, 10 mg once
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| | ARBs || [[Candesartan]] || 4 to 8 mg once, 32 mg once
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| | || [[Losartan]] || 25 to 50 mg once, 50 to 150 mg once
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| | || [[Valsartan]] || 20 to 40 mg twice, 160 mg twice
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| | [[Beta blockers]] || [[Bisoprolol]] || 1.25 mg once, 10 mg once
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| | || [[Carvedilol]] || 3.125 mg twice, 50 mg twice
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| | || [[Metoprolol succinate]] || 12.5 to 25.0 mg once, 200 mg once
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| | [[Aldosterone antagonists]]|| [[Spironolactone]] || 12.5 to 25.0 mg once, 25 mg once or twice
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| | || [[Eplerenone]] || 25 mg once, 50 mg once
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| | Inotropes || [[Dopamine]] || 5 to 10 mcg/kg/min
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| | || [[Dobutamine]] || 2.5 to 5 mcg/kg/min
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| | || [[Milrinone]] || 0.125 to 0.75 mcg/kg/min
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| | Vasodilators || [[Nitroglycerin]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min <br>every 3-5 mins as tolerated, max is 400mcg/min
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| | || [[Nitroprusside]] || 5 to 10 mcg/min, increase dose by 5-10mcg/min <br>every 5 mins as tolerated, max is 400mcg/min
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| | || [[Nesiritide]] || 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion,<br> maximum of 0.03 mcg/kg/minute
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| | [[Hydralazine]] and [[isosorbide dinitrate]] ||Fixed-dose combination || 37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, <br>75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
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| | ||Individual doses||[[Hydralazine]]: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses<br>[[Isosorbide dinitrate]]: 20 to 30 mg 3 or 4 times daily, 120 mg daily in divided doses
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| | [[Digoxin]] || || 0.125 to 0.25 mg daily
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| |}
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| ====Diuretic Therapy====
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| {{familytree/start}}
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| {{familytree | | | A01 | |A01='''Evidence of volume overload'''}}
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| {{familytree | | | |!| |}}
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| {{familytree | | | B01 | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">
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| ❑ [[Low sodium diet]] (<2 g daily)<br>
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| ❑ 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<br>
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| ❑ Commence IV [[diuretics]]<br>
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| :❑ [[Frusemide]] 40 mg, or
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| :❑ [[Torsemide]] 20 mg, or
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| :❑ [[Bumetanide]] 1 mg<br>
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| '''Contraindications'''<br>
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| ❑ [[Hypotension]] and [[cardiogenic shock]]<br><br>
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| '''Note''' - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)
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| </div>}}
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| {{familytree | | | |!| | | |}}
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| {{familytree | | | C01 | |C01='''Symptomatic improvement?'''}}
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| {{familytree | |,|-|^|-|.| | |}}
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| {{familytree | D01 | | D02 | |D01=Yes|D02=No}}
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| {{familytree | |!| | | |!| | |}}
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| {{familytree | E01 | | E02 | |E01=Maintain current IV diuretic dose|E02=Double IV [[diuretic]] dose <br>and titrate according to patient's response <br>or when the maximum dose is reached}}
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| {{familytree | |!| | | |!| | |}}
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| {{familytree | |!| | | F01 | |F01='''No symptomatic improvement'''}}
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| {{familytree | |!| |,|-|^|-|.| | |}}
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| {{familytree | |!| G01 | | G02 | |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Add'''<br>
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| ❑ Another diuretic e.g., IV [[chlorothiazide]] or oral [[metolazone]]<br>'''or'''<br>
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| ❑ An aldosterone antagonist e.g., [[spironolactone]] or [[eplerenone]], in post [[ST elevation myocardial infarction|MI]] patients</div><br>
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| |G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Adjuvants to diuretics'''<br>
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| ----
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| ❑ Low dose [[dopamine]] to preserve renal function and [[renal blood flow]]<br>
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| ❑ IV [[nitroprusside]], [[nitroglycerin]], or [[nesiritide]] for hemodynamically stable patients to relieve [[dyspnea]]<br>
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| ❑ Vasopressin antagonists (e.g. [[tolvaptan]]; start with 15mg orally daily) <ref name="pmid15113814">{{cite journal| author=Gheorghiade M, Gattis WA, O'Connor CM, Adams KF, Elkayam U, Barbagelata A et al.| title=Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 16 | pages= 1963-71 | pmid=15113814 | doi=10.1001/jama.291.16.1963 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15113814 }} </ref> <ref name="pmid11705818">{{cite journal| author=Udelson JE, Smith WB, Hendrix GH, Painchaud CA, Ghazzi M, Thomas I et al.| title=Acute hemodynamic effects of conivaptan, a dual V(1A) and V(2) vasopressin receptor antagonist, in patients with advanced heart failure. | journal=Circulation | year= 2001 | volume= 104 | issue= 20 | pages= 2417-23 | pmid=11705818 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11705818 }} </ref></div>}}
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| {{familytree | |!| |`|-|v|-|'| |}}
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| {{familytree | |!| | | H01 | | |H01=No symptomatic improvement<br>('''refractory edema''')}}
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| {{familytree | |!| | | |!| |}}
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| {{familytree | |!| | | I01 | |I01=[[Ultrafiltration]] or [[dialysis]]}}
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| {{familytree | |`|-|v|-|'| |}}
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| {{familytree | | | J01 | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''General measures'''<br>
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| ----
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| ❑ Monitor BP, volume status, congestion<br>❑ Daily weights<br>❑ Intake and output charts<br>
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| ❑ Convert all IV diuretic to oral<br>❑ Daily serum [[electrolytes]], [[urea]] & [[creatinine]]<br>❑ DVT prophylaxis</div>}}
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| {{familytree/end}}
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| ==Do's==
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| * Order an [[echocardiogram]] as soon as possible if no recent one available or if the patient's clinical status is deteriorating.
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| * Digitalis decreases hospitalization but not mortality. It can be beneficial in symptomatic patients with low EF.<ref>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.</ref><ref>Dobbs SM, Kenyon WI, Dobbs RJ. Maintenance digoxin after an
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| episode of heart failure: placebo-controlled trial in outpatients. Br Med J. 1977;1:749–52</ref><ref>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.</ref><ref>Guyatt GH, Sullivan MJ, Fallen EL, et al. A controlled trial of digoxin in congestive heart failure. Am J Cardiol. 1988;61:371–5.</ref><ref>. 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.</ref><ref>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.</ref><ref>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.</ref>
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| * Make sure your patient is on [[DVT]] prophylaxis unless contraindicated.<ref name="pmid12945875">{{cite journal| author=Alikhan R, Cohen AT, Combe S, Samama MM, Desjardins L, Eldor A et al.| title=Prevention of venous thromboembolism in medical patients with enoxaparin: a subgroup analysis of the MEDENOX study. | journal=Blood Coagul Fibrinolysis | year= 2003 | volume= 14 | issue= 4 | pages= 341-6 | pmid=12945875 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12945875 }} </ref><ref name="pmid22315257">{{cite journal| author=Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel| title=Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= 7S-47S | pmid=22315257 | doi=10.1378/chest.1412S3 | pmc=PMC3278060 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315257 }} </ref>
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| * 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.<ref name="pmid10471456">{{cite journal| author=Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A et al.| title=The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. | journal=N Engl J Med | year= 1999 | volume= 341 | issue= 10 | pages= 709-17 | pmid=10471456 | doi=10.1056/NEJM199909023411001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10471456 }} </ref><ref name="pmid21073363">{{cite journal| author=Zannad F, McMurray JJ, Krum H, van Veldhuisen DJ, Swedberg K, Shi H et al.| title=Eplerenone in patients with systolic heart failure and mild symptoms. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 1 | pages= 11-21 | pmid=21073363 | doi=10.1056/NEJMoa1009492 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21073363 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21558564 Review in: Evid Based Med. 2011 Aug;16(4):121-2] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21814643 Review in: J Fam Pract. 2011 Aug;60(8):482-4] </ref><ref name="pmid21029826">{{cite journal| author=Vizzardi E, D'Aloia A, Giubbini R, Bordonali T, Bugatti S, Pezzali N et al.| title=Effect of spironolactone on left ventricular ejection fraction and volumes in patients with class I or II heart failure. | journal=Am J Cardiol | year= 2010 | volume= 106 | issue= 9 | pages= 1292-6 | pmid=21029826 | doi=10.1016/j.amjcard.2010.06.052 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21029826 }} </ref>
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| * Start [[hydralazine]] and [[nitrates|isosorbide dinitrate]] to reduce morbidity or mortality in patients with current or prior symptomatic [[systolic dysfunction|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. <ref>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.</ref><ref>Cohn JN. The Vasodilator-Heart Failure Trials (V-HeFT). Mechanistic data from the VA Cooperative Studies. Introduction. Circulation. 1993; 87:VI1–4.</ref><ref>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.
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| 1999;5:178–87.</ref><ref>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.</ref><ref>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.</ref>
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| * Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.<ref name="pmid3793436">{{cite journal| author=Grosskopf I, Rabinovitz M, Rosenfeld JB| title=Combination of furosemide and metolazone in the treatment of severe congestive heart failure. | journal=Isr J Med Sci | year= 1986 | volume= 22 | issue= 11 | pages= 787-90 | pmid=3793436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3793436 }} </ref><ref name="pmid16189620">{{cite journal| author=Rosenberg J, Gustafsson F, Galatius S, Hildebrandt PR| title=Combination therapy with metolazone and loop diuretics in outpatients with refractory heart failure: an observational study and review of the literature. | journal=Cardiovasc Drugs Ther | year= 2005 | volume= 19 | issue= 4 | pages= 301-6 | pmid=16189620 | doi=10.1007/s10557-005-3350-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16189620 }} </ref>
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| * Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
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| * Use a combination of [[hydralazine]] and [[nitrates|isosorbide dinitrate]]. They have been proven to reduce morbidity or mortality in patients with current or prior symptomatic [[systolic dysfunction|HFrEF]] who cannot be given an [[ACE inhibitor]] or [[ARB]] because of drug intolerance, hypotension, or renal insufficiency, unless contraindicated.<ref>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.</ref><ref>Cohn JN. The Vasodilator-Heart Failure Trials (V-HeFT). Mechanistic data from the VA Cooperative Studies. Introduction. Circulation. 1993; 87:VI1–4.</ref><ref>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.
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| 1999;5:178–87.</ref><ref>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.</ref><ref>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.</ref>
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| * Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .<ref name="pmid10618565">{{cite journal| author=Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI| title=Predictors of readmission among elderly survivors of admission with heart failure. | journal=Am Heart J | year= 2000 | volume= 139 | issue= 1 Pt 1 | pages= 72-7 | pmid=10618565 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10618565 }} </ref><ref name="pmid20442387">{{cite journal| author=Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.| title=Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. | journal=JAMA | year= 2010 | volume= 303 | issue= 17 | pages= 1716-22 | pmid=20442387 | doi=10.1001/jama.2010.533 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20442387 }} </ref>
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| ==Don'ts==
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| * 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]]. <ref>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.</ref><ref>. 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.</ref><ref>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</ref><ref>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.</ref><ref>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.</ref><ref>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.</ref><ref>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.</ref>
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| * Don't Use parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute decompensated [[HF]] without evidence of decreased organ perfusion. <ref name="pmid11911756">{{cite journal |author=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 |title=Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=287 |issue=12 |pages=1541–7 |year=2002 |month=March |pmid=11911756 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11911756 |accessdate=2012-04-06}}</ref>
| |
| * Don't combine an [[ACEI]], [[ARB]], and [[aldosterone antagonist]] in patients with [[systolic dysfunction|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.<ref name="pmid15295047">{{cite journal| author=Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A et al.| title=Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 6 | pages= 543-51 | pmid=15295047 | doi=10.1056/NEJMoa040135 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15295047 }} </ref><ref name="pmid12535810">{{cite journal| author=Bozkurt B, Agoston I, Knowlton AA| title=Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 2 | pages= 211-4 | pmid=12535810 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12535810 }} </ref>
| |
| * Don't continue nutritional supplements with no proven benefit.
| |
| * Don't use statins routinely without other indications.<ref name="pmid14975476">{{cite journal| author=Horwich TB, MacLellan WR, Fonarow GC| title=Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 4 | pages= 642-8 | pmid=14975476 | doi=10.1016/j.jacc.2003.07.049 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14975476 }} </ref><ref name="pmid18757089">{{cite journal| author=Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG et al.| title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2008 | volume= 372 | issue= 9645 | pages= 1231-9 | pmid=18757089 | doi=10.1016/S0140-6736(08)61240-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757089 }} </ref>
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| ==References==
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| {{Reflist|2}}
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