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Treatment of Acute Decompensation of Heart Failure

		Initial stabilization: ❑ Assess the airway ❑ Position the patient upright at an angle of 45 degrees, with legs dangling off the bedside ❑ Check pulse oximetry ❑ If hypoxemia is present (Sa02 < 90% or Pa02 <60 mmHg), administer oxygen with/without noninvasive ventilation ❑ Avoid IV morphine (may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms) ❑ Ensure continuous cardiac monitoring ❑ Secure intravenous access with 18 gauge cannula ❑ Monitor vitals signs ❑ Monitor fluid intake and urine output Assess congestion and perfusion: Congestion at rest (dry vs. wet) "Wet" suggested by orthopnea, ↑JVP, rales, S3, pedal edema Low perfusion at rest (warm vs. cold) "Cold" suggested by narrow pulse pressure, cool extremities, hypotension The patient is: ❑ Warm and dry, OR ❑ Warm and wet, OR ❑ Cold and dry, OR ❑ Cold and wet Admit for in-hospital treatment if: ❑ Hypotension and/or cardiogenic shock ❑ Poor end-organ perfusion (worsening renal function, cold clammy extremities, altered mental status) ❑ Hypoxemia (Sa02 <90%) ❑ Atrial fibrillation with a rapid ventricular response resulting in hypotension ❑ Presence of an underlying condition, such as acute coronary syndrome Identify precipitating factor and treat accordingly: For more details on the manegemtn, click on the disease to be transferred to the resident survival guide ❑ Myocardial infarction ❑ Myocarditis ❑ Renal failure ❑ Hypertensive crisis ❑ Non adherence to medications ❑ Worsening aortic stenosis ❑ Drugs (NSAIDS, thiazides, calcium channel blocker, beta blockers) ❑ Toxins (alcohol, anthracyclines) ❑ Atrial fibrillation Rate control of atrial fibrillation is the mainstay of arrhythmia therapy. Avoid the use of drugs with negative inotropic effects such as beta blockers and non-dihydropyridine calcium channel blockers e.g., verapamil in the treatment of acute decompensated systolic heart failure Consider cardioversion if the patient is in cardiogenic shock or if new onset atrial fibrillation is the clear precipitant of the hemodynamic decompensation ❑ COPD ❑ Pulmonary embolism ❑ Anemia ❑ Thyroid abnormalities ❑ Systemic infection Treat congestion and optimize volume status: Diuretics ❑ IV loop diuretics as intermittent boluses or continuous infusion (I-B) ❑ Already on loop diuretics: IV dose >= home PO dose (I-B) ❑ Serial assessment of fluid intake and output, vital signs, body weight (measured every day at the same time) and symptoms ❑ Adjust dose according to volume status (I-B) ❑ Daily electrolytes, BUN, creatinine (I-C) ❑ Persistent symptoms: Increase dose of IV loop diuretics (I-B) OR Add a second diuretics, such as thiazide (I-B) ❑ Consider low dose dopamine infusion for improved diuresis and renal blood flow (IIb-B) ❑ Consider renal replacement therapy/Ultrafiltration in obvious volume overload (IIb-B) Venodilators ❑ Consider IV nitroglycerin, nitroprusside, or nesiritide as add-on to diuretics to relieve dyspnea (IIb-A) Treat low perfusion: ❑ Inotropes VTE prevention: ❑ Anticoagulation in the absence of contraindications (I-B) Chronic medical therapy: ❑ Chronic HFrEF and hemodynamically stable: continue medical therapy ❑ Initiate beat blockers at a low dose in stable patients following optimization of volume status and D/C IV diuretics and inotropes (I-B) Management of hyponatremia: ❑ Water restriction ❑ Optimization of chronic home medications ❑ Persistent hyponatremia and risk of cognitive impairment: vasopressin antagonist for short term (hypervolemic)

Prevention of Heart Failure in Stage A and B

What is the stage of heart failure (HF)?

Stage A At high risk for HF but without structural heart disease or symptoms of HF

Stage B Structural heart disease but without signs or symptoms of HF

❑ Encourage healthy lifestyle and exercise ❑ Treat hypertension ( I-A) ❑ Treat dyslipidemia (I-A) ❑ Control obesity (I-C) ❑ Treat DM (I-C) ❑ Avoid tobacco (I-C) ❑ Avoid cardiotoxic agents (I-C) ❑ Administer ACE-I if HTN, DM, CVD, PAD

❑ Encourage healthy lifestyle and exercise ❑ Treat hypertension (I-A) ❑ Treat dyslipidemia (I-A) ❑ Control obesity (I-C) ❑ Treat DM (I-C) ❑ Avoid tobacco (I-C) ❑ Avoid cardiotoxic agents (I-C)

Consider additional measures in selected patients: ❑ Administer ACE-I if history of MI or ACS and reduced EF to prevent symptoms and reduce mortality (I-A), in all decreased EF to prevent symptoms (I-A) ❑ Administer beta-blockers if history of MI or ACS and reduced EF to reduce mortality (I-B), in all reduced EF to prevent symptoms (I-C) ❑ Administer statins if history of MI or ACS to prevent symptoms (I-A) ❑ Consider ICD placement to prevent sudden death if asymptomatic ischemic cardiomyopathy, > 40 days post-MI, LVEF <= 30%, on adequate medical therapy, and good 1 year survival

Treatment of Heart Failure in Stage C and D

What is the stage of heart failure (HF)?

Stage C HFrEF Structural heart disease with prior or current symptoms of HF and reduced ejection fraction

Stage C HFpEF Structural heart disease with prior or current symptoms of HF and preserved ejection fraction

Stage D Refractory HF requiring specialized interventions

Exercise training (I-A) Education for self-care (I-B) Sodium restriction if symptomatic (IIa-C) Cardiac rehabilitation in patients clinically stable (IIa-B) Treatment of HTN, dyslipidemia, obesity, DM Avoid tobacco (I-C) Avoid cardiotoxic agents Medical therapy: Control systolic and diastolic blood pressure (I-B) Diuretics to decrease symptoms of congestion (I-C) Coronary revascularization in CAD and Sx (IIa-C) Treat concomitant Afib (IIa-C) BB, ACE-I, ARB for hypertension (IIa-C) ARB to decrease hospitalization (IIb-B)

Exercise training (I-A) Education for self-care (I-B) Sodium restriction if symptomatic (IIa-C) Cardiac rehabilitation in patients clinically stable (IIa-B) Treatment of HTN, dyslipidemia, obesity, DM Avoid tobacco (I-C) Avoid cardiotoxic agents Routine drugs: ACE-I or ARB (decrease mortality by 17%) (I-A) PLUS Beta blockers (decrease mortality by 34%) (I-A) Bisprolol Carvedilol Sustained release metoprolol succinate PLUS Loop diuretics (for symptomatic volume overload; Class II-IV) (I-A) PLUS Aldosterone antagonist NYHA class II with prior history of cardiovascular hospitalization or high BNP OR NYHA class III-IV, AND LVEF <=35%, AND estimated GFR>30 mL/min/1.73 m2, K+< 5 mEq/L (decrease mortality by 34%) (I-A) LVEF >=40% AND symptoms of HF or DM (I-B) Add-on drugs in selected patients: Persistent symptoms AND African American AND NYHA class III-IV already on ACE-I and beta blockers: Hydralazine nitrate (decrease mortality by 43%) (I-A) Contraindications to ACE-I or ARB (IIa-B) Digitalis: to decrease hospitalizations (IIa-B) NYHA class II–IV symptoms and HFrEF or HFpEF: Omega-3 polyunsaturated fatty acid supplementation (IIa-B)

Fluid restriction: Restriction to 1.5 to 2 L/d particularly in case of hyponatremia (IIa-C) Inotropes Temporary inotropes: in case of cardiogenic shock to maintain perfusion, awaiting definitive therapy or resolution of acute precipitating event (I-C), OR Continuous inotropes: Bridge therapy in stage D HF refractory to medical therapy and device therapy among patients eligible/awaiting MCS or heart transplant (IIa-B) Short-term, continuous intravenous inotropes to maintain perfusion among hospitalized, severe systolic dysfunction, low blood pressure and significantly decreased cardiac output (IIb-B) Long-term, continuous intravenous inotropes for symptom control in select patients with stage D HF despite optimal GDMT and device therapy who are not eligible for either MCS or cardiac transplantation (IIb-B) Mechanical circulatory support (MCS) Temporary MCS in HFrEF awaiting definitive therapy or resolution of acute precipitating event (I-B) Temporary MCS HFrEF with severe hemodynamic compromise, as a bridge therapy to recovery or decision (I-B) Durable MCS to prolong survival in selected patients (LVEF <25% and NYHA class III–IV functional status despite GDMT, including, when indicated, CRT, with either high predicted 1- to 2-year mortality, or dependence on continuous parenteral inotropic support, Multidisciplinary team) (I-B) Cardiac transplantation Refractory to medical therapy, device, and surgery (I-C)