Congestive heart failure positive inotropics: Difference between revisions

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| [[File:Siren.gif|30px|link= Congestive heart failure resident survival guide]]|| <br> || <br>
| [[Acute decompensated heart failure resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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| [[File:Critical_Pathways.gif|88px|link= Congestive heart failure critical pathways]]|| <br> || <br>
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{{Congestive heart failure}}
{{Congestive heart failure}}
{{CMG}}; {{AOEIC}} {{LG}}
{{CMG}}; {{AOEIC}} {{LG}} {{EdzelCo}}


==Overview==
==Overview==
Positive inotropes are agents that increase myocardial contractility, and are used to support cardiac function in conditions such as decompensated [[congestive heart failure]], [[cardiogenic shock]], [[septic shock]], [[myocardial infarction]], [[cardiomyopathy]], etc.  Examples of positive inotropes include [[digoxin]], [[dobutamine]], [[dopamine]] and [[phosphodiesterase-III inhibitor]]s like [[amrinone]] and [[milrinone]].
Positive inotropes are agents that increase myocardial contractility, and are used to support cardiac function in conditions such as decompensated [[congestive heart failure]], [[cardiogenic shock]], [[septic shock]], [[myocardial infarction]], [[cardiomyopathy]], etc.  Examples of positive inotropes include [[digoxin]], [[dobutamine]], [[dopamine]] and [[phosphodiesterase-III inhibitor]]s like [[amrinone]] and [[milrinone]].


==Pharmacologic Mechanisms==
==Inotropics==
===Pharmacologic Mechanisms===
#Agents that increase intracellular cAMP  
#Agents that increase intracellular cAMP  
#*Alpha-adrenergic agonists  
#*Alpha-adrenergic agonists  
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#*[[Vesnarinone]]
#*[[Vesnarinone]]


==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="Hunt"> Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. 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. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202</ref><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>==
===Digoxin===
 
===Positive Inotropics in Patients Presenting With Heart Failure (DO NOT EDIT) <ref name="Hunt"> Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. 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. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202</ref><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>===
 
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
 
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.'' Long-term use of an infusion of a positive inotropic drug may be harmful and is not recommended for patients with current or prior symptoms of [[heart failure]] and reduced [[left ventricular ejection fraction]] ([[LVEF]]), except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}
 
==Digoxin==
* Inhibits Na,K+-ATPase resulting in an increase in intracellular Na+, extracellular Ca2+ exchange increasing the velocity and extent of [[sarcomere]] shortening.
* Inhibits Na,K+-ATPase resulting in an increase in intracellular Na+, extracellular Ca2+ exchange increasing the velocity and extent of [[sarcomere]] shortening.
* ACC/AHA recommend [[digoxin]] for symptomatic patients with left ventricular systolic dysfunction.  
* ACC/AHA recommend [[digoxin]] for symptomatic patients with left ventricular systolic dysfunction.  
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* In the RALES study, a level of < 1 ng/ml was associated with efficacy.  Levels above 1 ng/ml were not associated with greater efficacy and were associated with higher mortality.
* In the RALES study, a level of < 1 ng/ml was associated with efficacy.  Levels above 1 ng/ml were not associated with greater efficacy and were associated with higher mortality.


===Digitalis in Patients Presenting With Heart Failure (DO NOT EDIT) <ref name="Hunt"> Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. 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. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202</ref><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>===
===Dobutamine===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
 
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Digitalis]] can be beneficial in patients with current or prior symptoms of [[heart failure]] and reduced [[left ventricular ejection fraction]] ([[LVEF]]) to decrease hospitalizations for [[heart failure]]. <ref name="pmid9036306">{{cite journal |author= |title=The effect of digoxin on mortality and morbidity in patients with heart failure. The Digitalis Investigation Group |journal=[[The New England Journal of Medicine]] |volume=336 |issue=8 |pages=525–33 |year=1997 |month=February |pmid=9036306 |doi=10.1056/NEJM199702203360801 |url=http://dx.doi.org/10.1056/NEJM199702203360801 |accessdate=2012-04-05}}</ref><ref name="pmid2447297">{{cite journal |author= |title=Comparative effects of therapy with captopril and digoxin in patients with mild to moderate heart failure. The Captopril-Digoxin Multicenter Research Group |journal=[[JAMA : the Journal of the American Medical Association]] |volume=259 |issue=4 |pages=539–44 |year=1988 |pmid=2447297 |doi= |url= |accessdate=2012-04-05}}</ref><ref name="pmid322793">{{cite journal |author=Dobbs SM, Kenyon WI, Dobbs RJ |title=Maintenance digoxin after an episode of heart failure: placebo-controlled trial in outpatients |journal=[[British Medical Journal]] |volume=1 |issue=6063 |pages=749–52 |year=1977 |month=March |pmid=322793 |pmc=1605598 |doi= |url= |accessdate=2012-04-05}}</ref><ref name="pmid7038483">{{cite journal |author=Lee DC, Johnson RA, Bingham JB, Leahy M, Dinsmore RE, Goroll AH, Newell JB, Strauss HW, Haber E |title=Heart failure in outpatients: a randomized trial of digoxin versus placebo |journal=[[The New England Journal of Medicine]] |volume=306 |issue=12 |pages=699–705 |year=1982 |month=March |pmid=7038483 |doi=10.1056/NEJM198203253061202 |url=http://www.nejm.org/doi/abs/10.1056/NEJM198203253061202?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-04-05}}</ref><ref name="pmid3277366">{{cite journal |author=Guyatt GH, Sullivan MJ, Fallen EL, Tihal H, Rideout E, Halcrow S, Nogradi S, Townsend M, Taylor DW |title=A controlled trial of digoxin in congestive heart failure |journal=[[The American Journal of Cardiology]] |volume=61 |issue=4 |pages=371–5 |year=1988 |month=February |pmid=3277366 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/0002-9149(88)90947-2 |accessdate=2012-04-05}}</ref><ref name="pmid2646536">{{cite journal |author=DiBianco R, Shabetai R, Kostuk W, Moran J, Schlant RC, Wright R |title=A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure |journal=[[The New England Journal of Medicine]] |volume=320 |issue=11 |pages=677–83 |year=1989 |month=March |pmid=2646536 |doi=10.1056/NEJM198903163201101 |url=http://www.nejm.org/doi/abs/10.1056/NEJM198903163201101?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-04-05}}</ref><ref name="pmid8409069">{{cite journal |author=Uretsky BF, Young JB, Shahidi FE, Yellen LG, Harrison MC, Jolly MK |title=Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. PROVED Investigative Group |journal=[[Journal of the American College of Cardiology]] |volume=22 |issue=4 |pages=955–62 |year=1993 |month=October |pmid=8409069 |doi= |url= |accessdate=2012-04-05}}</ref><ref name="pmid8505940">{{cite journal |author=Packer M, Gheorghiade M, Young JB, Costantini PJ, Adams KF, Cody RJ, Smith LK, Van Voorhees L, Gourley LA, Jolly MK |title=Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-converting-enzyme inhibitors. RADIANCE Study |journal=[[The New England Journal of Medicine]] |volume=329 |issue=1 |pages=1–7 |year=1993 |month=July |pmid=8505940 |doi=10.1056/NEJM199307013290101 |url=http://dx.doi.org/10.1056/NEJM199307013290101 |accessdate=2012-04-05}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|}
 
==Dobutamine==
* Activates beta-1 receptors resulting in enhanced [[cardiac contractility]].
* Activates beta-1 receptors resulting in enhanced [[cardiac contractility]].
* Long-term dobutamine infusions are [[arrhythmogenic]] and increase mortality.
* Long-term dobutamine infusions are [[arrhythmogenic]] and increase mortality.
* Dobutamine also slightly reduces afterload
* Dobutamine also slightly reduces afterload


==Dopamine==
===Dopamine===
Dopamine is associated with a dose dependent mechanism of action:
Dopamine is associated with a dose dependent mechanism of action:
* '''At low doses: (≤2 µg/kg/min),''' selectively dilate splanchnic and renal arterial beds and increase renal perfusion.
* '''At low doses: (≤2 µg/kg/min),''' selectively dilate splanchnic and renal arterial beds and increase renal perfusion.
Line 61: Line 49:
* '''At higher doses: (5 to 20 µg/kg/min),''' result in direct [[alpha-adrenergic receptor]] stimulation and increases [[systemic vascular resistance]].
* '''At higher doses: (5 to 20 µg/kg/min),''' result in direct [[alpha-adrenergic receptor]] stimulation and increases [[systemic vascular resistance]].


==Milrinone==
===Milrinone===
* [[Phosphodiesterase-III inhibitor]] that enhances [[cardiac contractility]] by increasing intracellular [[cyclic adenosine monophosphate]] ([[cAMP]]).  
* [[Phosphodiesterase-III inhibitor]] that enhances [[cardiac contractility]] by increasing intracellular [[cyclic adenosine monophosphate]] ([[cAMP]]).  
* Potent pulmonary [[vasodilator]] that may benefit some patients with [[pulmonary hypertension]].
* Potent pulmonary [[vasodilator]] that may benefit some patients with [[pulmonary hypertension]].
* Unlike dobutamine, [[milrinone]] is beneficial in decompensated heart failure patients who are on [[beta-blocker]] therapy.  
* Unlike dobutamine, [[milrinone]] is beneficial in decompensated heart failure patients who are on [[beta-blocker]] therapy.  
* Long term milrinone infusions are [[arrhythmogenic]], and increase mortality.
* Long term milrinone infusions are [[arrhythmogenic]], and increase mortality.
== 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) <ref name="pmid35363500">{{cite journal| author=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM | display-authors=etal| title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 18 | pages= e876-e894 | pmid=35363500 | doi=10.1161/CIR.0000000000001062 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35363500  }} </ref>==
=====[[Pharmacological]] [[Treatment]] for Stage C [[HFrEF]]: [[Digoxin]]=====
{|class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In [[patients]] with [[symptomatic]] [[HFrEF]] despite GDMT (or who are unable to tolerate GDMT), [[digoxin]] might be considered to decrease [[hospitalizations]] for [[HF]]. <ref name="pmid9036306">{{cite journal| author=Digitalis Investigation Group| title=The effect of digoxin on mortality and morbidity in patients with heart failure. | journal=N Engl J Med | year= 1997 | volume= 336 | issue= 8 | pages= 525-33 | pmid=9036306 | doi=10.1056/NEJM199702203360801 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9036306  }} </ref><ref name="pmid16339157">{{cite journal| author=Ahmed A, Rich MW, Love TE, Lloyd-Jones DM, Aban IB, Colucci WS | display-authors=etal| title=Digoxin and reduction in mortality and hospitalization in heart failure: a comprehensive post hoc analysis of the DIG trial. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 2 | pages= 178-86 | pmid=16339157 | doi=10.1093/eurheartj/ehi687 | pmc=2685167 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16339157  }} </ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|}
==External Link==
*[https://www.ahajournals.org/doi/epub/10.1161/CIR.0000000000001063.full.pdf 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines]<ref name="pmid35363499">{{cite journal |vauthors=Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW |title=2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=145 |issue=18 |pages=e895–e1032 |date=May 2022 |pmid=35363499 |doi=10.1161/CIR.0000000000001063 |url=}} </ref>


==References==
==References==
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Latest revision as of 21:15, 22 June 2022
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2] Edzel Lorraine Co, DMD, MD[3]

Overview

Positive inotropes are agents that increase myocardial contractility, and are used to support cardiac function in conditions such as decompensated congestive heart failure, cardiogenic shock, septic shock, myocardial infarction, cardiomyopathy, etc. Examples of positive inotropes include digoxin, dobutamine, dopamine and phosphodiesterase-III inhibitors like amrinone and milrinone.

Inotropics

Pharmacologic Mechanisms

  1. Agents that increase intracellular cAMP
  2. Agents that affect sarcolemmal ion pumps/channels
  3. Agents that modulate intracellular calcium mechanisms by either:
  4. Drugs having multiple mechanisms of action

Digoxin

  • Inhibits Na,K+-ATPase resulting in an increase in intracellular Na+, extracellular Ca2+ exchange increasing the velocity and extent of sarcomere shortening.
  • ACC/AHA recommend digoxin for symptomatic patients with left ventricular systolic dysfunction.
  • Commonly used in patients with heart failure and atrial fibrillation to reduce the ventricular response rate.
  • Mortality has not been shown to be improved with use of digoxin[1], but the use of digoxin has been associated with a reduction in hospitalization in the RALES study.
  • There is no need to load a CHF patient with digoxin. For the majority of patients with normal renal function, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate.
  • Drugs that increase the concentration of digoxin include antibiotics and anticholinergic agents as well as amiodarone, quinidine and verapamil.
  • In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels above 1 ng/ml were not associated with greater efficacy and were associated with higher mortality.

Dobutamine

  • Activates beta-1 receptors resulting in enhanced cardiac contractility.
  • Long-term dobutamine infusions are arrhythmogenic and increase mortality.
  • Dobutamine also slightly reduces afterload

Dopamine

Dopamine is associated with a dose dependent mechanism of action:

Milrinone

2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [2]

Pharmacological Treatment for Stage C HFrEF: Digoxin
Class IIb
"1. In patients with symptomatic HFrEF despite GDMT (or who are unable to tolerate GDMT), digoxin might be considered to decrease hospitalizations for HF. [1][3] (Level of Evidence: B-R) "

External Link

References

  1. ↑ 1.0 1.1 "The effect of digoxin on mortality and morbidity in patients with heart failure. The Digitalis Investigation Group". The New England Journal of Medicine. 336 (8): 525–33. 1997. doi:10.1056/NEJM199702203360801. PMID 9036306. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  2. ↑ Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM; et al. (2022). "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 145 (18): e876–e894. doi:10.1161/CIR.0000000000001062. PMID 35363500 Check |pmid= value (help).
  3. ↑ Ahmed A, Rich MW, Love TE, Lloyd-Jones DM, Aban IB, Colucci WS; et al. (2006). "Digoxin and reduction in mortality and hospitalization in heart failure: a comprehensive post hoc analysis of the DIG trial". Eur Heart J. 27 (2): 178–86. doi:10.1093/eurheartj/ehi687. PMC 2685167. PMID 16339157.
  4. ↑ Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW (May 2022). "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 145 (18): e895–e1032. doi:10.1161/CIR.0000000000001063. PMID 35363499 Check |pmid= value (help).

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