2013 ACCF/AHA Guideline The Hospitalized Patient: Difference between revisions

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| [[Heart failure resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
| [[Heart failure resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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| [[File:Physician_Extender_Algorithms.gif|88px|link=Heart failure physician extender algorithm]]|| <br> || <br>
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{{Congestive heart failure}}
{{Congestive heart failure}}
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==Classification of Acute Decompensated HF==
==Classification of Acute Decompensated HF==


==2009 ACC/AHA Focused Update and 2005 Guidelines for the Diagnosis and Management of Chronic Heart Failure in the Adult (DO NOT EDIT) <ref name="pmid19324967">Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19324967 2009 focused update: ACCF/AHA 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.] ''Circulation'' 119 (14):1977-2016. [http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192064 DOI:10.1161/CIRCULATIONAHA.109.192064] PMID: [http://pubmed.gov/19324967 19324967]</ref>==
==2013 ACCF/AHA Guideline/2009 ACC/AHA Focused Update and 2005 Guideline for the Diagnosis and Management of Heart Failure in the Adult (DO NOT EDIT) <ref name="pmid19324967">Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19324967 2009 focused update: ACCF/AHA 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.] ''Circulation'' 119 (14):1977-2016. [http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192064 DOI:10.1161/CIRCULATIONAHA.109.192064] PMID: [http://pubmed.gov/19324967 19324967]</ref>==


===Hospitalized Patients Presenting With Heart Failure (DO NOT EDIT) <ref name="pmid19324967">Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19324967 2009 focused update: ACCF/AHA 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.] ''Circulation'' 119 (14):1977-2016. [http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192064 DOI:10.1161/CIRCULATIONAHA.109.192064] PMID: [http://pubmed.gov/19324967 19324967]</ref>===
===Hospitalized Patients Presenting With Heart Failure (DO NOT EDIT) <ref name="pmid19324967">Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19324967 2009 focused update: ACCF/AHA 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.] ''Circulation'' 119 (14):1977-2016. [http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192064 DOI:10.1161/CIRCULATIONAHA.109.192064] PMID: [http://pubmed.gov/19324967 19324967]</ref>===
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' The diagnosis of [[heart failure]] is primarily based on signs and symptoms derived from a thorough [[Congestive heart failure history and symptoms|history]] and [[Congestive heart failure physical examination|physical examination]]. Clinicians should determine the following:
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Acute coronary syndrome]] precipitating acute [[heart failure]] decompensation should be promptly identified by [[Congestive heart failure electrocardiogram|electrocardiogram]] and serum biomarkers, including [[Troponin#Diagnostic Use|cardiac troponin]] testing, and treated optimally as appropriate to the overall condition and prognosis of the patient. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
:'''a.''' Adequacy of systemic perfusion;
:'''b.''' Volume status;
:'''c.''' The contribution of precipitating factors and/or comorbidities;
:'''d.''' If the [[heart failure]] is new onset or an exacerbation of chronic disease; and
:'''e.''' Whether it is associated with preserved [[ejection fraction]]. <nowiki>"</nowiki>
 
<nowiki>"</nowiki> [[Congestive heart failure chest x ray|Chest radiographs]], [[Congestive heart failure electrocardiogram|electrocardiogram]], and [[Congestive heart failure echocardiography|echocardiography]] are key tests in this assessment. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
 
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Concentrations of [[BNP|B-type natriuretic peptide]] ([[BNP]]) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) should be measured in patients being evaluated for [[dyspnea]] in which the contribution of [[heart failure]] is not known. Final diagnosis requires interpreting these results in the context of all available clinical data and ought not to be considered a stand alone test.<ref name="pmid12124404">{{cite journal |author=Maisel AS, Krishnaswamy P, Nowak RM, McCord J, Hollander JE, Duc P, Omland T, Storrow AB, Abraham WT, Wu AH, Clopton P, Steg PG, Westheim A, Knudsen CW, Perez A, Kazanegra R, Herrmann HC, McCullough PA |title=Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure |journal=[[The New England Journal of Medicine]] |volume=347 |issue=3 |pages=161–7 |year=2002 |month=July |pmid=12124404 |doi=10.1056/NEJMoa020233 |url=http://dx.doi.org/10.1056/NEJMoa020233 |accessdate=2012-04-06}}</ref><ref name="pmid17548729">{{cite journal |author=Moe GW, Howlett J, Januzzi JL, Zowall H |title=N-terminal pro-B-type natriuretic peptide testing improves the management of patients with suspected acute heart failure: primary results of the Canadian prospective randomized multicenter IMPROVE-CHF study |journal=[[Circulation]] |volume=115 |issue=24 |pages=3103–10 |year=2007 |month=June |pmid=17548729 |doi=10.1161/CIRCULATIONAHA.106.666255 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=17548729 |accessdate=2012-04-06}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
 
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' [[Acute coronary syndrome]] precipitating acute [[heart failure]] decompensation should be promptly identified by [[Congestive heart failure electrocardiogram|electrocardiogram]] and serum biomarkers, including [[Troponin#Diagnostic Use|cardiac troponin]] testing, and treated optimally as appropriate to the overall condition and prognosis of the patient. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>


|-
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' Common precipitating factors for [[HF|acute HF]] should be considered during initial evaluation, as recognition of these conditions is critical to guide appropriate therapy: ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Common precipitating factors for [[HF|acute HF]] should be considered during initial evaluation, as recognition of these conditions is critical to guide appropriate therapy: ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
: '''a.''' Nonadherence with medication regimen, sodium and/or fluid restriction;
: '''a.''' Nonadherence with medication regimen, sodium and/or fluid restriction;
: '''b.''' [[Acute coronary syndromes| Acute myocardial ischemia]];
: '''b.''' [[Acute coronary syndromes| Acute myocardial ischemia]];
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: '''h.''' Excessive alcohol or illicit drug use;
: '''h.''' Excessive alcohol or illicit drug use;
: '''i.''' Endocrine abnormalities (e.g., diabetes mellitus, hyperthyroidism, hypothyroidism) ;
: '''i.''' Endocrine abnormalities (e.g., diabetes mellitus, hyperthyroidism, hypothyroidism) ;
: '''j.''' Concurrent[[Infections]] (e.g., pneumonia, viral illnesses); and
: '''j.''' Concurrent [[Infections]] (e.g., pneumonia, viral illnesses); and
: '''k.''' Additional acute cardiovascular disorders (e.g., valve disease endocarditis, myopericarditis, aortic dissection).<nowiki>"</nowiki>
: '''k.''' Additional acute cardiovascular disorders (e.g., valve disease endocarditis, myopericarditis, aortic dissection).<nowiki>"</nowiki>


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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' [[Oxygen therapy]] should be administered to relieve symptoms related to [[hypoxemia]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Measurement of BNP or NT-proBNP is useful to support clinical judgment for the diagnosis of acutely decompensated HF, especially in the setting of uncertainty for the diagnosis. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>


|-
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' Whether the diagnosis of [[heart failure]] is new or chronic, patients who present with rapid decompensation and [[hypoperfusion]] associated with decreasing urine output and other manifestations of [[shock]] are critically ill and rapid intervention should be used to improve systemic perfusion. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' Measurement of BNP or NT-proBNP and/or cardiac troponin is useful for establishing prognosis or disease severity in acutely decompensated HF. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
 
|-
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''7.''' Patients with [[HF]] admitted with evidence of significant fluid overload should be promptly treated with intravenous loop diuretics to reduce morbidity. <ref name="pmid18158472">{{cite journal |author=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 |title=Practical recommendations for prehospital and early in-hospital management of patients presenting with acute heart failure syndromes |journal=[[Critical Care Medicine]] |volume=36 |issue=1 Suppl |pages=S129–39 |year=2008 |month=January |pmid=18158472 |doi=10.1097/01.CCM.0000296274.51933.4C |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0090-3493&volume=36&issue=1&spage=S129 |accessdate=2012-04-06}}</ref><ref name="pmid17643575">{{cite journal |author=Costanzo MR, Johannes RS, Pine M, Gupta V, Saltzberg M, Hay J, Yancy CW, Fonarow GC |title=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 |journal=[[American Heart Journal]] |volume=154 |issue=2 |pages=267–77 |year=2007 |month=August |pmid=17643575 |doi=10.1016/j.ahj.2007.04.033 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-8703(07)00357-2 |accessdate=2012-04-06}}</ref><ref name="pmid17408803">{{cite journal |author=Silvers SM, Howell JM, Kosowsky JM, Rokos IC, Jagoda AS |title=Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with acute heart failure syndromes |journal=[[Annals of Emergency Medicine]] |volume=49 |issue=5 |pages=627–69 |year=2007 |month=May |pmid=17408803 |doi=10.1016/j.annemergmed.2006.10.024 |url=http://linkinghub.elsevier.com/retrieve/pii/S0196-0644(06)02461-9 |accessdate=2012-04-06}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' If patients are already receiving loop diuretic therapy, the initial intravenous dose should equal or exceed their chronic oral daily dose and should be given as either intermittent boluses or continuous infusion. Urine output and signs and symptoms of congestion should be serially assessed, and the diuretic dose should be adjusted accordingly to relieve symptoms, reduce volume excess, and avoid hypotension. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' Patients with suspected or new-onset HF, or those presenting with acute decompensated HF, should undergo a chest x-ray to assess heart size and pulmonary congestion and to detect alternative cardiac, pulmonary, and other diseases that may cause or contribute to the patient’s symptoms. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>


|-
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''8.''' The effect of [[HF]] treatment should be monitored with careful measurement of fluid intake and output, [[vital signs]], body weight that is determined at the same time each day, and clinical signs and symptoms of systemic perfusion and congestion. Daily serum electrolytes, [[blood urea nitrogen|urea nitrogen]], and [[creatinine]] concentrations should be measured during the use of intravenous diuretics or active titration of [[HF]] medications. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' A 2-dimensional echocardiogram with Doppler should be performed during initial evaluation of patients presenting with HF to assess ventricular function, size, wall thickness, wall motion, and valve function. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>


|-
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''11.''' [[Congestive heart failure invasive monitoring|Invasive hemodynamic monitoring]] should be performed to guide therapy in patients who are in [[respiratory distress]] or with clinical evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''7.''' Repeat measurement of EF and measurement of the severity of structural remodeling are useful to provide information in patients with HF who have had a significant change in clinical status; who have experienced or recovered from a clinical event; or who have received treatment, including GDMT, that might have had a significant effect on cardiac function; or who may be candidates for device therapy. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
 
|-
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''12.''' Medications should be reconciled in every patient and adjusted as appropriate on admission to and discharge from the hospital. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''8.''' Invasive hemodynamic monitoring with a pulmonary artery catheter should be performed to guide therapy in patients who have respiratory distress or clinical evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C ]])'' <nowiki>"</nowiki>


|-
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''13.''' In patients with HFrEF experiencing a symptomatic exacerbation of HF requiring hospitalization during chronic maintenance treatment with GDMT, it is recommended that GDMT be continued in the absence of hemodynamic instability or contraindications. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''9.''' Patients with [[HF]] admitted with evidence of significant fluid overload should be promptly treated with intravenous loop diuretics to reduce morbidity. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>


|-
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''14.''' In patients hospitalized with [[heart failure]] with [[EF|reduced ejection fraction]] not treated with oral therapies known to improve outcomes, particularly [[Congestive heart failure ACE inhibitors or angiotensin receptor blockers|ACE inhibitors]] or [[Congestive heart failure ACE inhibitors or angiotensin receptor blockers|ARBs]] and [[Congestive heart failure beta blockers|beta blocker therapy]], initiation of these therapies is recommended in stable patients prior to hospital discharge. <ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref><ref name="pmid18617067">{{cite journal |author=Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, O'Connor CM, Sun JL, Yancy CW, Young JB |title=Influence of beta-blocker continuation or withdrawal on outcomes in patients hospitalized with heart failure: findings from the OPTIMIZE-HF program |journal=[[Journal of the American College of Cardiology]] |volume=52 |issue=3 |pages=190–9 |year=2008 |month=July |pmid=18617067 |doi=10.1016/j.jacc.2008.03.048 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(08)01503-9 |accessdate=2012-04-06}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''10.''' If patients are already receiving loop diuretic therapy, the initial intravenous dose should equal or exceed their chronic oral daily dose and should be given as either intermittent boluses or continuous infusion. Urine output and signs and symptoms of congestion should be serially assessed, and the diuretic dose should be adjusted accordingly to relieve symptoms, reduce volume excess, and avoid hypotension. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>


|-
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''15.''' Initiation of beta-blocker therapy is recommended after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotropic agents. Beta-blocker therapy should be initiated at a low dose and only in stable patients. Caution should be used when initiating beta blockers in patients who have required inotropes during their hospital course.<ref name="pmid17581778">{{cite journal |author=Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA |title=Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET |journal=[[European Journal of Heart Failure]] |volume=9 |issue=9 |pages=901–9 |year=2007 |month=September |pmid=17581778 |doi=10.1016/j.ejheart.2007.05.011 |url=http://eurjhf.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17581778 |accessdate=2012-04-06}}</ref><ref name="pmid18617067">{{cite journal |author=Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, O'Connor CM, Sun JL, Yancy CW, Young JB |title=Influence of beta-blocker continuation or withdrawal on outcomes in patients hospitalized with heart failure: findings from the OPTIMIZE-HF program |journal=[[Journal of the American College of Cardiology]] |volume=52 |issue=3 |pages=190–9 |year=2008 |month=July |pmid=18617067 |doi=10.1016/j.jacc.2008.03.048 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(08)01503-9 |accessdate=2012-04-06}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''11.''' If patients are already receiving loop diuretic therapy, the initial intravenous dose should equal or exceed their chronic oral daily dose and should be given as either intermittent boluses or continuous infusion. Urine output and signs and symptoms of congestion should be serially assessed, and the diuretic dose should be adjusted accordingly to relieve symptoms, reduce volume excess, and avoid hypotension. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
 
|-
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''16.''' A patient admitted to the hospital with decompensated [[HF]] should receive venous thromboembolism prophylaxis with an anticoagulant medication if the risk-benefit ratio is favorable. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''12.''' The effect of [[HF]] treatment should be monitored with careful measurement of fluid intake and output, [[vital signs]], body weight that is determined at the same time each day, and clinical signs and symptoms of systemic perfusion and congestion. Daily serum electrolytes, [[blood urea nitrogen|urea nitrogen]], and [[creatinine]] concentrations should be measured during the use of intravenous diuretics or active titration of [[HF]] medications. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>


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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''17.''' In all patients hospitalized with [[heart failure]], both with preserved and low [[ejection fraction]], transition should be made from intravenous to oral [[Congestive heart failure diuretics|diuretic therapy]] with careful attention to oral diuretic dosing and monitoring of [[electrolytes]]. With all medication changes, the patient should be monitored for supine and upright [[hypotension]], [[renal dysfunction|worsening renal function]] and [[heart failure]] [[Congestive heart failure physical examination|signs]]/[[Congestive heart failure history and symptoms|symptoms]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''13.''' In patients with HFrEF experiencing a symptomatic exacerbation of HF requiring hospitalization during chronic maintenance treatment with GDMT, it is recommended that GDMT be continued in the absence of hemodynamic instability or contraindications. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>


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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''17.''' Comprehensive written discharge instructions for all patients with a hospitalization for [[heart failure]] and their caregivers is strongly recommended, with special emphasis on the following 6 aspects of care:  <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''14.''' Initiation of beta-blocker therapy is recommended after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotropic agents. Beta-blocker therapy should be initiated at a low dose and only in stable patients. Caution should be used when initiating beta blockers in patients who have required inotropes during their hospital course. <ref name="Fonarow-2008">{{Cite journal  | last1 = Fonarow | first1 = GC. | last2 = Abraham | first2 = WT. | last3 = Albert | first3 = NM. | last4 = Stough | first4 = WG. | last5 = Gheorghiade | first5 = M. | last6 = Greenberg | first6 = BH. | last7 = O'Connor | first7 = CM. | last8 = Sun | first8 = JL. | last9 = Yancy | first9 = CW. | title = Influence of beta-blocker continuation or withdrawal on outcomes in patients hospitalized with heart failure: findings from the OPTIMIZE-HF program. | journal = J Am Coll Cardiol | volume = 52 | issue = 3 | pages = 190-9 | month = Jul | year = 2008 | doi = 10.1016/j.jacc.2008.03.048 | PMID = 18617067 }}</ref>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
:'''a.''' [[Diet]],
:'''b.''' Discharge medications, with a special focus on adherence, persistence, and uptitration to recommended doses of [[Congestive heart failure ACE inhibitors or angiotensin receptor blockers|ACE inhibitor]]/[[Congestive heart failure ACE inhibitors or angiotensin receptor blockers|ARB]] and [[Congestive heart failure beta blockers|beta blocker]] medication,
:'''c.''' [[Congestive heart failure and exercise|Activity level]],
:'''d.''' Follow-up appointments,
:'''e.''' Daily [[weight]] monitoring, and
:'''f.''' What to do if [[heart failure]] [[Congestive heart failure history and symptoms|symptoms]] worsen. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


|-
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''18.''' Postdischarge systems of care, if available, should be used to facilitate the transition to effective outpatient care for patients hospitalized with [[heart failure]]. <ref name="pmid15312864">{{cite journal |author=McAlister FA, Stewart S, Ferrua S, McMurray JJ |title=Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials |journal=[[Journal of the American College of Cardiology]] |volume=44 |issue=4 |pages=810–9 |year=2004 |month=August |pmid=15312864 |doi=10.1016/j.jacc.2004.05.055 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(04)01123-4 |accessdate=2012-04-06}}</ref><ref name="pmid15381518">{{cite journal |author=Lappé JM, Muhlestein JB, Lappé DL, Badger RS, Bair TL, Brockman R, French TK, Hofmann LC, Horne BD, Kralick-Goldberg S, Nicponski N, Orton JA, Pearson RR, Renlund DG, Rimmasch H, Roberts C, Anderson JL |title=Improvements in 1-year cardiovascular clinical outcomes associated with a hospital-based discharge medication program |journal=[[Annals of Internal Medicine]] |volume=141 |issue=6 |pages=446–53 |year=2004 |month=September |pmid=15381518 |doi= |url= |accessdate=2012-04-06}}</ref><ref name="pmid8185149">{{cite journal |author=Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M |title=Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial |journal=[[Annals of Internal Medicine]] |volume=120 |issue=12 |pages=999–1006 |year=1994 |month=June |pmid=8185149 |doi= |url= |accessdate=2012-04-06}}</ref><ref name="pmid15086645">{{cite journal |author=Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS |title=Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial |journal=[[Journal of the American Geriatrics Society]] |volume=52 |issue=5 |pages=675–84 |year=2004 |month=May |pmid=15086645 |doi=10.1111/j.1532-5415.2004.52202.x |url=http://onlinelibrary.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=0002-8614&date=2004&volume=52&issue=5&spage=675 |accessdate=2012-04-06}}</ref><ref name="pmid12816174">{{cite journal |author=Windham BG, Bennett RG, Gottlieb S |title=Care management interventions for older patients with congestive heart failure |journal=[[The American Journal of Managed Care]] |volume=9 |issue=6 |pages=447–59; quiz 460–1 |year=2003 |month=June |pmid=12816174 |doi= |url=http://www.ajmc.com/pubMed.php?pii=11 |accessdate=2012-04-06}}</ref><ref name="pmid15026403">{{cite journal |author=Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR |title=Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis |journal=[[JAMA : the Journal of the American Medical Association]] |volume=291 |issue=11 |pages=1358–67 |year=2004 |month=March |pmid=15026403 |doi=10.1001/jama.291.11.1358 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=15026403 |accessdate=2012-04-06}}</ref><ref name="pmid15642765">{{cite journal |author=Koelling TM, Johnson ML, Cody RJ, Aaronson KD |title=Discharge education improves clinical outcomes in patients with chronic heart failure |journal=[[Circulation]] |volume=111 |issue=2 |pages=179–85 |year=2005 |month=January |pmid=15642765 |doi=10.1161/01.CIR.0000151811.53450.B8 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=15642765 |accessdate=2012-04-06}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''15.''' A patient admitted to the hospital with decompensated [[HF]] should receive venous thromboembolism prophylaxis with an anticoagulant medication if the risk-benefit ratio is favorable. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|}


{|class="wikitable"
|-
|-
|colspan="1" style="text-align:center; background:LightCoral"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''16.''' Throughout the hospitalization as appropriate, before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed: ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
 
:''' a.'''  Initiation of GDMT if not previously established and not contraindicated;
:''' b.'''  Precipitant causes of HF, barriers to optimal care transitions, and limitations in postdischarge support;
:''' c.'''  Assessment of volume status and supine/upright hypotension with adjustment of HF therapy as appropriate;
:''' d.'''  Titration and optimization of chronic oral HF therapy;
:''' e.'''  Assessment of renal function and electrolytes where appropriate;
:''' f.'''  Assessment and management of comorbid conditions;
:''' g.'''  Reinforcement of HF education, self-care, emergency plans, and need for adherence; and
:''' h.'''  Consideration for palliative care or hospice care in selected patients.<nowiki>"</nowiki>
|-
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Use of parenteral [[Congestive heart failure positive inotropics|inotropes]] in [[normotensive]] patients with acute [[decompensated HF]] without evidence of decreased organ perfusion is not recommended. <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> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''17.''' The use of performance improvement systems and/or evidence-based systems of care is recommended in the hospital and early postdischarge outpatient setting to identify appropriate [[HF]] patients for GDMT, provide clinicians with useful reminders to advance GDMT, and assess the clinical response. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' Routine use of [[Congestive heart failure invasive monitoring|invasive hemodynamic monitoring]] in normotensive patients with acute [[decompensated HF]] and congestion with symptomatic response to [[Congestive heart failure diuretics|diuretics]] and [[Congestive heart failure vasodilators|vasodilators]] is not recommended. <ref name="pmid16204662">{{cite journal |author=Binanay C, Califf RM, Hasselblad V, O'Connor CM, Shah MR, Sopko G, Stevenson LW, Francis GS, Leier CV, Miller LW |title=Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=294 |issue=13 |pages=1625–33 |year=2005 |month=October |pmid=16204662 |doi=10.1001/jama.294.13.1625 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=16204662 |accessdate=2012-04-06}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''18.''' Multidisciplinary [[HF]] disease-management programs are recommended for patients at high risk for hospital readmission, to facilitate the implementation of GDMT, to address different barriers to behavioral change, and to reduce the risk of subsequent rehospitalization for [[HF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|}
|}
{|class="wikitable"
{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' When patients present with acute [[heart failure]] and known or suspected [[MI|acute myocardial ischemia]] due to occlusive coronary disease, especially when there are signs and symptoms of inadequate systemic perfusion, urgent [[Congestive heart failure cardiac catheterization|cardiac catheterization]] and revascularization is reasonable where it is likely to prolong meaningful survival. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>


|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' When diuresis is inadequate to relieve symptoms, it is reasonable to intensify the diuretic regimen using either: ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' When diuresis is inadequate to relieve symptoms, it is reasonable to intensify the diuretic regimen using either: ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
:'''a.''' Higher doses of [[Congestive heart failure diuretics#Loop Diuretics|loop diuretics]]; or
:'''a.''' Higher doses of [[Congestive heart failure diuretics#Loop Diuretics|loop diuretics]]; or
:'''b.''' Addition of a second diuretic (e.g.,  [[Congestive heart failure diuretics#Thiazide Diuretics|thiazide]]).
:'''b.''' Addition of a second diuretic (e.g.,  [[Congestive heart failure diuretics#Thiazide Diuretics|thiazide]]).
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' [[Congestive heart failure invasive monitoring|Invasive hemodynamic monitoring]] can be useful for carefully selected patients with acute [[heart failure]] who have persistent symptoms despite empiric adjustment of standard therapies, and ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Scheduling an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge is reasonable. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
:'''a.''' whose fluid status, perfusion, or systemic or pulmonary vascular resistances are uncertain,
|-
:'''b.''' whose systolic pressure remains low, or is associated with symptoms, despite initial therapy,
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' Use of clinical risk-prediction tools and/or biomarkers to identify patients at higher risk for postdischarge clinical events is reasonable. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
:'''c.''' whose [[renal dysfunction|renal function is worsening]] with therapy
:'''d.''' who require parenteral [[Congestive heart failure positive inotropics|vasoactive agents]] or
:'''e.''' who may need consideration for advanced device therapy or [[Congestive heart failure cardiac transplantation|transplantation]].
|}
|}


Line 128: Line 109:
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Intravenous [[Congestive heart failure positive inotropics|inotropic drugs]] such as [[dopamine]], [[dobutamine]] or [[milrinone]] might be reasonable for those patients presenting with documented severe [[systolic dysfunction]], [[hypotension|low blood pressure]] and evidence of low [[cardiac output]], with or without congestion, to maintain systemic perfusion and preserve end-organ performance. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' The usefulness of BNP- or NT-proBNP-guided therapy for acutely decompensated HF is not well established. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>


|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Low-dose[[ dopamine]] infusion may be considered in addition to [[loop diuretic]] therapy to improve diuresis and better preserve renal function and renal blood flow. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Measurement of other clinically available tests such as biomarkers of myocardial injury or fibrosis may be considered for additive risk stratification in patients with acutely decompensated HF. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' Low-dose[[ dopamine]] infusion may be considered in addition to [[loop diuretic]] therapy to improve diuresis and better preserve renal function and renal blood flow. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>


|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' [[Congestive heart failure ultrafiltration|Ultrafiltration]] may be considered for patients with obvious volume overload to alleviate congestive symptoms and fluid weight.'' ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' [[Congestive heart failure ultrafiltration|Ultrafiltration]] may be considered for patients with obvious volume overload to alleviate congestive symptoms and fluid weight.'' ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>


|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' [[Congestive heart failure ultrafiltration|Ultrafiltration]]  may be considered for patients with refractory congestion not responding to medical therapy.'' ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.''' [[Congestive heart failure ultrafiltration|Ultrafiltration]]  may be considered for patients with refractory congestion not responding to medical therapy.'' ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>


|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.''' If symptomatic [[hypotension]] is absent, intravenous [[nitroglycerin]], [[nitroprusside]] or [[nesiritide]] may be considered an adjuvant to [[Congestive heart failure diuretics|diuretics]] for relief of dyspnea in patients admitted with acutely decompensated [[HF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''6.''' If symptomatic [[hypotension]] is absent, intravenous [[nitroglycerin]], [[nitroprusside]] or [[nesiritide]] may be considered an adjuvant to [[Congestive heart failure diuretics|diuretics]] for relief of dyspnea in patients admitted with acutely decompensated [[HF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>


|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''6.''' In patients hospitalized with volume overload, including [[HF]], who have persistent severe hyponatremia and are at risk for or having active cognitive symptoms despite water restriction and maximization of GDMT, vasopressin antagonists may be considered in the short term to improve serum sodium concentration in hypervolemic, hyponatremic states with either a V2 receptor selective or a nonselective vasopressin antagonist. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''7.''' In patients hospitalized with volume overload, including [[HF]], who have persistent severe hyponatremia and are at risk for or having active cognitive symptoms despite water restriction and maximization of GDMT, vasopressin antagonists may be considered in the short term to improve serum sodium concentration in hypervolemic, hyponatremic states with either a V2 receptor selective or a nonselective vasopressin antagonist. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>


|}
|}
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==References==
==References==
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Latest revision as of 20:06, 29 July 2020
Resident
Survival
Guide
Congestive Heart Failure Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Systolic Dysfunction
Diastolic Dysfunction
HFpEF
HFrEF

Causes

Differentiating Congestive heart failure from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Clinical Assessment

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

Cardiac MRI

Echocardiography

Exercise Stress Test

Myocardial Viability Studies

Cardiac Catheterization

Other Imaging Studies

Other Diagnostic Studies

Treatment

Invasive Hemodynamic Monitoring

Medical Therapy:

Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF
Diuretics
ACE Inhibitors
Angiotensin receptor blockers
Aldosterone Antagonists
Beta Blockers
Ca Channel Blockers
Nitrates
Hydralazine
Positive Inotropics
Anticoagulants
Angiotensin Receptor-Neprilysin Inhibitor
Antiarrhythmic Drugs
Nutritional Supplements
Hormonal Therapies
Drugs to Avoid
Drug Interactions
Treatment of underlying causes
Associated conditions

Exercise Training

Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Ultrafiltration
Cardiac Surgery
Left Ventricular Assist Devices (LVADs)
Cardiac Transplantation

ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

2013 ACCF/AHA Guideline The Hospitalized Patient On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on 2013 ACCF/AHA Guideline The Hospitalized Patient

CDC on 2013 ACCF/AHA Guideline The Hospitalized Patient

2013 ACCF/AHA Guideline The Hospitalized Patient in the news

Blogs on 2013 ACCF/AHA Guideline The Hospitalized Patient

Directions to Hospitals Treating 2013 ACCF/AHA Guideline The Hospitalized Patient

Risk calculators and risk factors for 2013 ACCF/AHA Guideline The Hospitalized Patient

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Classification of Acute Decompensated HF

2013 ACCF/AHA Guideline/2009 ACC/AHA Focused Update and 2005 Guideline for the Diagnosis and Management of Heart Failure in the Adult (DO NOT EDIT) [1]

Hospitalized Patients Presenting With Heart Failure (DO NOT EDIT) [1]

Class I
"1. Acute coronary syndrome precipitating acute heart failure decompensation should be promptly identified by electrocardiogram and serum biomarkers, including cardiac troponin testing, and treated optimally as appropriate to the overall condition and prognosis of the patient. (Level of Evidence: C) "
"2. Common precipitating factors for acute HF should be considered during initial evaluation, as recognition of these conditions is critical to guide appropriate therapy: (Level of Evidence: C) "
a. Nonadherence with medication regimen, sodium and/or fluid restriction;
b. Acute myocardial ischemia;
c. Uncorrected high blood pressure;
d. AF and other arrhythmias;
e. Recent addition of negative inotropic drugs (e.g., verapamil, nifedipine, diltiazem, beta blockers);
f. Pulmonary emboli;
g. Initiation of drugs that increase salt retention (e.g., steroids, thiazolidinediones, NSAIDs);
h. Excessive alcohol or illicit drug use;
i. Endocrine abnormalities (e.g., diabetes mellitus, hyperthyroidism, hypothyroidism) ;
j. Concurrent Infections (e.g., pneumonia, viral illnesses); and
k. Additional acute cardiovascular disorders (e.g., valve disease endocarditis, myopericarditis, aortic dissection)."
"3. Measurement of BNP or NT-proBNP is useful to support clinical judgment for the diagnosis of acutely decompensated HF, especially in the setting of uncertainty for the diagnosis. (Level of Evidence: A) "
"4. Measurement of BNP or NT-proBNP and/or cardiac troponin is useful for establishing prognosis or disease severity in acutely decompensated HF. (Level of Evidence: A) "
"5. Patients with suspected or new-onset HF, or those presenting with acute decompensated HF, should undergo a chest x-ray to assess heart size and pulmonary congestion and to detect alternative cardiac, pulmonary, and other diseases that may cause or contribute to the patient’s symptoms. (Level of Evidence: C) "
"6. A 2-dimensional echocardiogram with Doppler should be performed during initial evaluation of patients presenting with HF to assess ventricular function, size, wall thickness, wall motion, and valve function. (Level of Evidence: C) "
"7. Repeat measurement of EF and measurement of the severity of structural remodeling are useful to provide information in patients with HF who have had a significant change in clinical status; who have experienced or recovered from a clinical event; or who have received treatment, including GDMT, that might have had a significant effect on cardiac function; or who may be candidates for device therapy. (Level of Evidence: C) "
"8. Invasive hemodynamic monitoring with a pulmonary artery catheter should be performed to guide therapy in patients who have respiratory distress or clinical evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment. (Level of Evidence: C ) "
"9. Patients with HF admitted with evidence of significant fluid overload should be promptly treated with intravenous loop diuretics to reduce morbidity. (Level of Evidence: B) "
"10. If patients are already receiving loop diuretic therapy, the initial intravenous dose should equal or exceed their chronic oral daily dose and should be given as either intermittent boluses or continuous infusion. Urine output and signs and symptoms of congestion should be serially assessed, and the diuretic dose should be adjusted accordingly to relieve symptoms, reduce volume excess, and avoid hypotension. (Level of Evidence: B) "
"11. If patients are already receiving loop diuretic therapy, the initial intravenous dose should equal or exceed their chronic oral daily dose and should be given as either intermittent boluses or continuous infusion. Urine output and signs and symptoms of congestion should be serially assessed, and the diuretic dose should be adjusted accordingly to relieve symptoms, reduce volume excess, and avoid hypotension. (Level of Evidence: B) "
"12. The effect of HF treatment should be monitored with careful measurement of fluid intake and output, vital signs, body weight that is determined at the same time each day, and clinical signs and symptoms of systemic perfusion and congestion. Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of intravenous diuretics or active titration of HF medications. (Level of Evidence: C) "
"13. In patients with HFrEF experiencing a symptomatic exacerbation of HF requiring hospitalization during chronic maintenance treatment with GDMT, it is recommended that GDMT be continued in the absence of hemodynamic instability or contraindications. (Level of Evidence: B) "
"14. Initiation of beta-blocker therapy is recommended after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotropic agents. Beta-blocker therapy should be initiated at a low dose and only in stable patients. Caution should be used when initiating beta blockers in patients who have required inotropes during their hospital course. [2](Level of Evidence: B) "
"15. A patient admitted to the hospital with decompensated HF should receive venous thromboembolism prophylaxis with an anticoagulant medication if the risk-benefit ratio is favorable. (Level of Evidence: B) "
"16. Throughout the hospitalization as appropriate, before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed: (Level of Evidence: B)
a. Initiation of GDMT if not previously established and not contraindicated;
b. Precipitant causes of HF, barriers to optimal care transitions, and limitations in postdischarge support;
c. Assessment of volume status and supine/upright hypotension with adjustment of HF therapy as appropriate;
d. Titration and optimization of chronic oral HF therapy;
e. Assessment of renal function and electrolytes where appropriate;
f. Assessment and management of comorbid conditions;
g. Reinforcement of HF education, self-care, emergency plans, and need for adherence; and
h. Consideration for palliative care or hospice care in selected patients."
"17. The use of performance improvement systems and/or evidence-based systems of care is recommended in the hospital and early postdischarge outpatient setting to identify appropriate HF patients for GDMT, provide clinicians with useful reminders to advance GDMT, and assess the clinical response. (Level of Evidence: B) "
"18. Multidisciplinary HF disease-management programs are recommended for patients at high risk for hospital readmission, to facilitate the implementation of GDMT, to address different barriers to behavioral change, and to reduce the risk of subsequent rehospitalization for HF. (Level of Evidence: B) "
Class IIa
"1. When diuresis is inadequate to relieve symptoms, it is reasonable to intensify the diuretic regimen using either: (Level of Evidence: B) "
a. Higher doses of loop diuretics; or
b. Addition of a second diuretic (e.g., thiazide).
"2. Scheduling an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge is reasonable. (Level of Evidence: B) "
"3. Use of clinical risk-prediction tools and/or biomarkers to identify patients at higher risk for postdischarge clinical events is reasonable. (Level of Evidence: B) "
Class IIb
"1. The usefulness of BNP- or NT-proBNP-guided therapy for acutely decompensated HF is not well established. (Level of Evidence: A) "
"2. Measurement of other clinically available tests such as biomarkers of myocardial injury or fibrosis may be considered for additive risk stratification in patients with acutely decompensated HF. (Level of Evidence: C) "
"3. Low-dosedopamine infusion may be considered in addition to loop diuretic therapy to improve diuresis and better preserve renal function and renal blood flow. (Level of Evidence: B) "
"4. Ultrafiltration may be considered for patients with obvious volume overload to alleviate congestive symptoms and fluid weight. (Level of Evidence: B) "
"5. Ultrafiltration may be considered for patients with refractory congestion not responding to medical therapy. (Level of Evidence: C) "
"6. If symptomatic hypotension is absent, intravenous nitroglycerin, nitroprusside or nesiritide may be considered an adjuvant to diuretics for relief of dyspnea in patients admitted with acutely decompensated HF. (Level of Evidence: A) "
"7. In patients hospitalized with volume overload, including HF, who have persistent severe hyponatremia and are at risk for or having active cognitive symptoms despite water restriction and maximization of GDMT, vasopressin antagonists may be considered in the short term to improve serum sodium concentration in hypervolemic, hyponatremic states with either a V2 receptor selective or a nonselective vasopressin antagonist. (Level of Evidence: B) "

Vote on and Suggest Revisions to the Current Guidelines

External Links

References

  1. ↑ 1.0 1.1 1.2 Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA 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. Circulation 119 (14):1977-2016. DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967
  2. ↑ Fonarow, GC.; Abraham, WT.; Albert, NM.; Stough, WG.; Gheorghiade, M.; Greenberg, BH.; O'Connor, CM.; Sun, JL.; Yancy, CW. (2008). "Influence of beta-blocker continuation or withdrawal on outcomes in patients hospitalized with heart failure: findings from the OPTIMIZE-HF program". J Am Coll Cardiol. 52 (3): 190–9. doi:10.1016/j.jacc.2008.03.048. PMID 18617067. Unknown parameter |month= ignored (help)
  3. ↑ Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al. (2005) ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 112 (12):e154-235. DOI:10.1161/CIRCULATIONAHA.105.167586 PMID: 16160202


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