Heart failure resident survival guide

For acute heart failure prevention click here.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahmoud Sakr, M.D. [2]; Ayokunle Olubaniyi, M.B,B.S [3]; Rim Halaby, M.D. [4]

Acute Heart Failure Resident Survival Guide Microchapters
Overview
Classification
Causes
FIRE
Diagnosis
Treatment Stage A and B Stage C and D Diuretic Therapy Medication Dosages
Do's
Don'ts

Overview

Heart failure is a complex syndrome characterized by inadequate blood ejection or impaired ventricular filling, leading to the inability of the heart to pump blood to meet the metabolic demands of the body. Heart failure is a clinical syndrome for which the diagnosis relies mainly on symptoms and physical examination findings. The main symptoms and signs of heart failure are dyspnea, volume overload (leading to pulmonary edema and/or peripheral edema), fatigue, and exercise intolerance. Acute decompensated heart failure (ADHF) is a life-threatening condition that can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure. Symptoms of ADHF may include dyspnea secondary to pulmonary edema, peripheral edema, hypotension, and impaired end organ perfusion that can manifest by worsening renal function, altered mental status, and cold clammy extremities. The mainstays of treatment of ADHF are 1) oxygen therapy to improve hypoxia, 2) diuresis to reduce both preload and intravascular volume, and 3) vasodilators to reduce afterload. The goals of treatment for chronic heart failure are to relieve symptoms, decrease hospitalization rate, and decrease morbidity and mortality. Treatment of heart failure includes identification and management of precipitating factors, lifestyle changes, pharmacological therapy, and devices.

Classification

Classification by Severity of Congestive Heart Failure

Shown below is a table comparing American College of Cardiology Foundation/American Heart Association (ACCF/AHA) stages to New York Heart Association (NYHA) classification of severity of heart failure.

ACCF/AHA Stages		New York Heart Association (NYHA) Classification
Stage	Interpretation	Class	Interpretation
A	At high risk for heart failure (HF) but without structural heart disease or symptoms of HF	-	-
B	Structural heart disease but without signs or symptoms of HF	I	No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF
C	Structural heart disease with prior or current symptoms of HF	I	No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF
		II	Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
		III	Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
		IV	Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest
D	Refractory HF requiring specialized interventions	IV	Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest

Classification by Other Factors

Left Ventricular Ejection Fraction (LVEF)

• Heart failure with reduced ejection fraction (HFrEF) or systolic heart failure: ejection fraction (EF) ≤40%
• Heart failure with preserved ejection fraction (HFpEF) or diastolic heart failure: EF ≥50%
  • Borderline HFpEF: EF between 41 to 49%
  • Improved HFpEF: EF >40% following a HFrEF

Cardiac Output

• Low cardiac output
• High stroke volume with/without cardiac output

Left vs. Right Sided

• Left sided: Pulmonary edema
• Right sided: Peripheral edema, elevated jugular venous pressure, hepatomegaly

Backwards vs. Forward

• Backwards: Congestion, elevated filling pressure
• Forwards: Low systemic perfusion

Causes

Life Threatening Causes

Acute decompensated heart failure is life threatening and should be treated as such irrespective of the underlying cause.

Common Causes

• Acute coronary syndrome
• Acute kidney injury
• Acute severe myocarditis
• Cardiac arrhythmias
• Cardiomyopathy
• Cardiotoxic agents - alcohol, cocaine
• Decompensation of an underlying chronic heart failure
• Hypertensive crisis
• Pulmonary embolus
• Systemic Inflammatory response syndrome
• Valvular heart disease

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients of severe acute decompensated heart failure in need of immediate intervention.

Boxes in red signify that an urgent management is needed.

Abbreviations: BU: Blood urea nitrogen; COPD: Chronic obstructive pulmonary disease; D5W: 5% dextrose solution in water ; HF: Heart failure; IV: Intravenous; MAP: Mean arterial pressure; Na: Sodium; NSAID: Non steroidal anti-inflammatory drug; SBP: Systolic blood pressure; S3: Third heart sound;

Identify cardinal findings that increase the pretest probability of acute decompensated heart failure ❑ Dyspnea ❑ Cool extremities ❑ Peripheral edema ❑ Decreased urine output ❑ Past medical history of heart failure ❑ History of orthopnea and paroxysmal nocturnal dyspnea ❑ Pulmonary crepitations/rales/crackles ❑ Third heart sound (S3)

Does the patient have any of the following findings that require hospitalization and urgent management? ❑ Severe decompendated HF: ❑ Hypotension (SBP < 90 mmHg or drop in MAP >30 mmHg) and/or cardiogenic shock ❑ Altered mental status ❑ Cold and clammy extremities ❑ Urine output <0.5mL/kg/hr ❑ Dyspnea at rest manifested by tachypnea or oxygen saturation <90% ❑ Atrial fibrillation with a rapid ventricular response resulting in hypotension ❑ Acute coronary syndrome

Yes

No

Admit to to a level of care that allows for constant ECG monitoring given the risk of arrhythmia

Proceed to complete diagnostic approach

Initial stabilization: ❑ Assess the airway ❑ Position the patient upright at an angle of 45 degrees, with legs dangling off the bedside (decrease preload) ❑ Monitor heart rate and blood pressure continuously ❑ Monitor oxygen saturation continuously ❑ If hypoxemia is present (Sa02 < 90% or Pa02 <60 mmHg), administer oxygen with/without noninvasive ventilation ❑ Morphine to decrease symptoms and Afterload (avoid IV morphine, may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms) ❑ Secure intravenous access with 18 gauge cannula ❑ Monitor fluid intake and urine output carefully (guide the adjustment of the diuretics dose) 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 Identify precipitating factor and treat accordingly: Click on the precipitating factor for more details on the management ❑ 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 ❑ Administer IV loop diuretics as intermittent boluses or continuous infusion (I-B) ❑ If patient is already on loop diuretics: IV dose ≥ home PO dose (I-B); rule of thumb: IV dose = 2.5x equivalent oral daily dose ❑ If patient is not already on loop diuretics, administer IV starting dose: Furosemide 20 to 40 mg, OR Torsemide 5 to 10 mg, OR Bumetanide 0.5 to 1 mg ❑ Adjust dose according to volume status (I-B) ❑ Perform serial assessment of fluid intake and output, vital signs, daily body weight (measured every day, with the same scale, at the same time, after first void) and symptoms ❑ Order daily electrolytes, BUN, creatinine (I-C) ❑ Low sodium diet (<2 g daily) ❑ In case of persistent symptoms: ❑ Increase dose of IV loop diuretics (I-B)- double dose at 2 hour interval up to maximal daily dose Furosemide maximal dose: 40 to 80 mg Torsemide maximal dose: 20 to 40 mg Bumetanide maximal dose: 1 to 2 mg 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) refractory to higher dose/combination of IV diuretics Venodilators ❑ Consider IV nitroglycerin, nitroprusside, or nesiritide as add-on to diuretics to relieve dyspnes (IIb-A) Do not administer vesodilators among patients with hypotension. Treat low perfusion: ❑ Inotropes (click her for details) If the total body and intravascular volumes are overloaded and the patient is normotensive, then diuresis alone should be undertaken. If the patient is volume overloaded but hypotensive, then inotropes must be administered in addition to diuretics. Invasive hemodynamic monitoring: ❑ Consider pulmonary artery catheterization in case of failure to respond to medical therapy, respiratory distress, shock, uncertainty regarding volume status, or increase in creatinine; assess the following parameters: ❑ PCWP ❑ Cardiac output ❑ Systemic vascular resistance VTE prevention: ❑ Anticoagulation in the absence of contraindications (I-B) Chronic medical therapy: ❑ Chronic ACE inhibitor: Hold if patient is hemodynamically unstable ❑ Chronic beta blocker: Hold if patient is hemodynamically unstable and/or in need or inotropes Decrease dose by ≥ half if patient is in moderate heart failure ❑ DO NOT INITIATE ACE INHIBITORS during an acute decompensation ❑ DO NOT INITIATE BETA BLOCKER during an acute decompensation; initiate beat blockers at a low dose in stable patients following optimization of volume status and D/C IV diuretics and inotropes (I-B) Monitor laboratory tests: ❑ BUN ❑ Creatinine ❑ Sodium (to detect hyponatremia which carries a poor prognosis), chloride, bicarbonate (to detect contraction alkalosis) and serum potassium (to detect hypokalemia as a result of diuresis and which can precipitate arrhythmias), potassium, magnesium Management of hyponatremia: ❑ Water restriction ❑ <2 L/day if the Na is < 130 meq/L ❑ < 1 L/day or more if the Na is < 125 meq/L Keep in min that juices are essentially free water with sugar. In the hyponatremia patient, drips should not be in D5W. ❑ Optimization of chronic home medications ❑ Persistent hyponatremia and risk of cognitive impairment: vasopressin antagonist for short term (hypervolemic)

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.

Abbreviations: ANA: Antinuclear antibody; ARDS: Acute respiratory distress syndrome; BNP: B-type natriuretic peptide; BUN: Blood urea nitrogen; CAD: Coronary artery disease; CBC: Complete blood count; CCB: Calcium channel blocker; CHF: Congestive heart failure; CT: Computed tomography; CXR: Chest X-ray; DM: Diabetes mellitus; ECG: Electrocardiogram; JVP: Jugular venous pressure; HF: Heart failure; HTN: Hypertension; LVEF: Left ventricular ejection fraction; LVH: Left ventricular hypertrophy; MI: Myocardial infarction; MRI: Magnetic resonance imaging; NT-pro BNP: N-terminal pro-brain natriuretic peptide; OCPs: Oral contraceptive pills; PAWP: Pulmonary artery wedge pressure; SBP: Systolic blood pressure; S1: First heart sound; S3: Third heart sound; TSH: Thyroid stimulating hormone

Characterize the symptoms: Symptoms of left-sided fluid accumulation: ❑ Dyspnea ❑ At rest ❑ Exertional ❑ Paroxysmal nocturnal dyspnea ❑ Orthopnea ❑ Cough Symptoms of right-sided fluid accumulation: ❑ Peripheral edema ❑ Right upper quadrant abdominal discomfort ❑ Bloating ❑ Satiety Symptoms of reduced cardiac output: ❑ Fatigue ❑ Exercise intolerance ❑ Oliguria ❑ Dizziness ❑ Syncope ❑ Altered mental status ❑ Cyanosis ❑ Anorexia ❑ Abdominal pain (suggestive of mesenteric ischemia) Symptoms suggestive of precipitating events: ❑ Chest pain (suggestive of myocardial ischemia) ❑ Palpitations (suggestive of arrhythmias) ❑ Fever (suggestive of infection) Nonspecific symptoms: ❑ Nausea ❑ Weight loss Obtain a detailed history: ❑ Past medical history ❑ Atrial fibrillation ❑ Cardiomyopathy ❑ Diabetes mellitus ❑ Hypertension ❑ Myocarditis ❑ Previous myocardial infarction ❑ Prior heart failure ❑ Sleep apnea ❑ Thyroid disease ❑ Valvular heart disease ❑ Medication history ❑ Noncompliance with previously prescribed medications for heart failure ❑ Intake of the following drugs: ❑ Alcohol ❑ Beta blockers ❑ Calcium channel blockers like verapamil which can exacerbate CHF or diltiazem which can cause peripheral edema ❑ Chemotherapy drugs - anthracyclines ❑ NSAIDs which should not be given in CHF ❑ Thiazolidinedione ❑ Family history ❑ History of dilated cardiomyopathy ❑ Radiation to the chest Determine the NYHA classification based on symptoms: ❑ Class I (no symptoms) ❑ Class II (symptoms with ordinary activities) ❑ Class III (symptoms upon minimal activity) ❑ Class IV (symptoms at rest)

Examine the patient: General appearance: ❑ Ill-looking ❑ In respiratory distress ❑ In upright sitting position Vitals: ❑ Temperature ❑ Fever (suggestive of underlying infection) ❑ Pulse ❑ Tachycardia ❑ Narrow pulse pressure (<25% of SBP) ❑ Blood pressure ❑ Hypotension (suggestive of circulatory collapse) ❑ Hypertension ❑ Respiration ❑ Tachypnea (most common symptom) ❑ Pulse oximetry (maintain oxygen sat ≥ 94% unless COPD) Weight: ❑ Measure weight daily at the same time after the first void ❑ Subtract 'dry weight' from current weight to estimate extent of volume overload and edema Skin ❑ Cool and clammy (suggestive of hypoperfusion) ❑ Cyanosis (suggestive of severe hypoxemia) ❑ Anasarca ❑ Jaundice (suggestive of liver dysfunction secondary to right-sided fluid overload) Neck examination: ❑ Jugular vein distention (suggestive of right-sided fluid overload) ❑ Positive hepatojugular reflux (suggestive of right-sided fluid overload) Respiratory examination ❑ Tachypnea ❑ Wheeze ❑ Dullness at lung bases (suggestive of pleural effusion, may be present in chronic HF secondary to lymphatic compensation) ❑ Crackles/crepitations/rales (suggestive of pleural effusion) ❑ Cheyne-stokes respiration Cardiovascular examination ❑ Displaced apex beat (suggestive of enlarged left ventricle) ❑ Parasternal heave (suggestive of elevated right ventricular pressure) ❑ S3 (typical) or S4 or both ❑ Soft S1 ❑ Pulsus alternans ❑ S4 (suggestive of diastolic dysfunction) ❑ New or changed murmur (suggestive of an underlying valvular heart diseases) ❑ Mitral regurgitation - Holosystolic murmur ❑ Aortic regurgitation - Decrescendo diastolic murmur ❑ Aortic stenosis - Crescendo-decrescendo systolic ejection murmur with ejection click Abdominal examination The following findings suggest volume overload and / or poor forward cardiac output: ❑ Hepatojugular reflux ❑ Hepatomegaly ❑ Ascites Extremity examination ❑ Pedal edema Neurological examination ❑ Altered mental status ❑ Syncope (suggestive of aortic stenosis or pulmonary embolism) Determine status of congestion and perfusion based on physical exam: Congestion at rest (dry vs. wet) "Wet" suggested by orthopnea, ↑JVP, positive hepatojugular reflux, abnormal valsalva response, rales, dullness upon percussion in bases, S3, peripheral edema, hepatomegaly, ascites, jaundice Low perfusion at rest (warm vs. cold) "Cold" suggested by narrow pulse pressure, cool extremities, hypotension, soft S1, pulsus alternans, decreased urinary output The patient is: ❑ Warm and dry, OR ❑ Warm and wet, OR ❑ Cold and dry, OR ❑ Cold and wet

Order tests: Routine (Class I, level of evidence C) ❑ CBC (rule out anemia) ❑ Troponin ❑ Elevated in myocardial ischemia and acute cardiogenic pulmonary edema, particularly if creatinine clearance (CrCl) is reduced ❑ Troponin T ≥ 0.1 ng/mL (associated with poor survival) ❑ Electrolytes ❑ Sodium: hyponatremia may occur due to fluid overlaod ❑ Serum calcium ❑ Serum magnesium can be lowered by diuresis ❑ Serum bicarbonate: to monitor contraction alkalosis with diuresis ❑ BUN, creatinine: may be elevated due to poor renal perfusion ❑ Urinalysis ❑ Fasting blood sugar ❑ Fasting lipid profile ❑ Liver function tests: can be elevated secondary to peripheral hypoperfusion ❑ TSH ❑ BNP or NT-pro BNP (if diagnosis is uncertain) Heart failure is unlikely if: ❑ BNP ≤ 100 pg/mL, or ❑ NT-pro BNP ≤ 300 pg/mL ❑ Chest X-ray (Class I, level of evidence C) ❑ Cardiomegaly (cardiothoracic ratio >50%) ❑ Cardiogenic pulmonary edema ❑ Kerley B lines ❑ Peribronchial cuffing ❑ Cephalization Chest X-ray findings in a patient with acute heart failure ❑ ECG (to help identify the cause of heart failure) ❑ Low QRS voltage (suggestive of infiltrative or dilated cardiomyopathy) ❑ Arrhythmia (atrial fibrillation carries a poor prognosis and requires slowing of the heart rate to improve filling & cardiac output) ❑ Poor R wave progression (suggestive of a prior MI) ❑ Left ventricular hypertrophy (consistent with a history of hypertension) ❑ Left bundle branch block (LBBB) due to prior MI, may result in dysynchrony) ❑ Left atrial enlargement (due to valvular disease or hypertension) ❑ Non-specific ST segment and T wave changes may suggest ischemia ❑ 2-D echocardiography with Doppler (Class I, level of evidence C) ❑ Assess chambers size, wall thickness, wall motion, and valve function ❑ Assess ejection fraction ❑ Radionuclide ventriculography or MRI ❑ To assess LVEF and volume when echocardiography is inadequate ❑ To assess myocardial infiltrative processes or scar burden (MRI) ❑ Coronary angiography looking for CAD ❑ Comprehensive metabolic panel if no evidence of CAD on coronary angiography ❑ Consider pulmonary artery catheterization in case of failure to respond to medical therapy, respiratory distress, shock, uncertainty regarding volume status, or increase in creatinine; assess the following parameters: ❑ PCWP ❑ Cardiac output ❑ Systemic vascular resistance Order additional tests to rule out other etiologies: ❑ ANA and rheumatoid factor (for rheumatologic diseases) ❑ Diagnostic tests for hemochromatosis and pheochromocytoma ❑ Endomyocardial biopsy (when myocarditis is suspected)

Consider alternative diagnoses: Alternative diagnoses Features Acute asthma ❑ Wheeze ❑ Reversal of symptoms following administration of bronchodilators COPD ❑ Increased cough ❑ Increased dyspnea ❑ Increased sputum production ARDS ❑ Severe hypoxia ❑ Bilateral opacities on chest X-ray ❑ PCWP < 15 mmHg Pneumonia ❑ Fever, cough, sputum ❑ Consolidation on chest X-ray Pulmonary embolism ❑ Pleuritic chest pain, cough, S4 ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on CT pulmonary angiography

Assess the stage of heart failure using the ACCF/AHA staging system to guide chronic therapy

Stage C ❑ Patients with structural heart disease This refers to patients with the following: ❑ Previous MI ❑ LV remodeling* (including LVH + low EF) ❑ Asymptomatic valvular disease AND ❑ Signs or symptoms of heart failure *LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury

Stage D ❑ Refractory heart failure ❑ Marked symptoms at rest ❑ Recurrent hospitalizations

Prevention of Heart Failure in Stage A and B

Shown below is an algorithm depicting the management of stage A and B heart failure.

Abbreviations: ACE I: Angiotensin converting enzyme inhibitor; ACS: Acute coronary syndrome; CVD: Cardiovascular disease; DM: Diabetes mellitus; EF: Ejection fraction; HF: Heart failure; HTN: Hypertension; ICD: Implantable cardioverter defibrillator; MI: Myocardial infarction; PAD: Peripheral artery disease

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

Shown below is an algorithm depicting the management of stage C and D heart failure.

Abbreviations: ACE I: Angiotensin converting enzyme inhibitor; ARB: Angiotensin II receptor blocker; ACS: Acute coronary syndrome; BID: Twice a day; BNP: Brain natriuretic peptide; CRT: Cardiac resynchronization therapy CVD: Cardiovascular disease; DM: Diabetes mellitus; EF: Ejection fraction; GDMT: Guideline determined medial therapy; GFR: Glomerular filtration rate; HF: Heart failure; HFrEF: Heart failure reduced ejectoon fraction; HFpEF: Heart failure preserved ejection fraction; HTN: Hypertension; ICD: Implantable cardioverter defibrillator; LVEF: Left ventricular ejection fraction; MCS: Mechanical circulatory support; NYHA: New York Heart Association; MI: Myocardial infarction; PAD: Peripheral artery disease; TID: Three times a day

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) Oral diuretics to decrease symptoms of congestion (I-C) Starting dose: ❑ Furosemide 20 to 40 mg, OR ❑ Torsemide 10 to 20 mg, OR ❑ Bumetanide 0.5 to 1 mg Monitor volume status and adjust dose No response: double oral diuretics dose rather than administer BID No or minimal response despite maximal diuretic dose: Administer diuretics BID or TID Coronary revascularization in symptomatic CAD (IIa-C) Treat concomitant AF (IIa-C) Beta blocker, ACE-I, ARB for hypertension (IIa-C) ARB to decrease hospitalization (IIb-B) ARNI to decrease morbidity and mortality (I-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) Bisoprolol Carvedilol Sustained release metoprolol succinate PLUS Loop diuretics (for symptomatic volume overload; Class II-IV) (I-A) Starting dose: ❑ Furosemide 20 to 40 mg, OR ❑ Torsemide 10 to 20 mg, OR ❑ Bumetanide 0.5 to 1 mg Monitor volume status and adjust dose No response: double oral diuretics dose rather than administer BID No or minimal response despite maximal diuretic dose: Administer diuretics BID or TID 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)

Medications

Drug Class	Drug	Daily dose	Maximum daily dose
Loop diuretics	Furosemide (duration of action: 6 to 8 h)	PO dose for chronic heart failure: 20 to 40 mg once or twice IV dose for acute heart failure: Initial dose given slowly (1 to 2 minutes) ❑ If patient is already on loop diuretics: IV dose ≥ home PO dose (rule of thumb: IV dose = 2.5x equivalent oral daily dose) ❑ If patient is not already on loop diuretics, administer IV starting dose of 20 to 40 mg Continuous IV infusion: Initial IV bolus administered slowly over 1 to 2 minutes, then continuous IV infusion rate of 10-40 mg/h|| 600 mg
	Bumetanide (duration of action: 4 to 6 h)	PO dose for chronic heart failure: 0.5 to 1.0 mg once or twice	10 mg
	Torsemide (duration of action: 12 to 16 h)	PO dose for chronic heart failure: 10 to 20 mg once	200 mg
Thiazide diuretics	Chlorothiazide (duration of action: 6 to 12 h)	PO: 250 to 500 mg once or twice	1000 mg
	Hydrochlorothiazide (duration of action: 6 to 12 h)	PO: 25 mg once or twice	200 mg
	Metolazone (duration of action: 12 to 24 h)	PO: 2.5 mg once	20 mg
K+- sparing diuretic	Amiloride (duration of action: 24 h)	PO: 5 mg once	20 mg
	Spironolactone (duration of action: 1 to 3 h)	PO: 12.5 to 25.0 mg once	50 mg
	Triamterene (duration of action: 7 to 9 h)	PO: 50 to 75 mg twice	200 mg
ACE inhibitors	Enalapril	2.5 mg twice	10 to 20 mg twice
	Lisinopril	2.5 to 5 mg once	20 to 40 mg once
	Ramipril	1.25 to 2.5 mg once	10 mg once
ARBs	Candesartan	4 to 8 mg once	32 mg once
	Losartan	25 to 50 mg once	50 to 150 mg once
	Valsartan	20 to 40 mg twice	160 mg twice
Beta blockers	Bisoprolol	1.25 mg once	10 mg once
	Carvedilol	3.125 mg twice	50 mg twice
	Carvedilol CR	10 mg once	80 mg once
	Metoprolol succinate extended release	12.5 to 25.0 mg once	200 mg once
Aldosterone antagonists	Spironolactone	12.5 to 25.0 mg once	25 mg once or twice
	Eplerenone	25 mg once	50 mg once
Inotropes	Dopamine	5 to 10 mcg/kg/min, OR 10 to 15 mcg/kg/min
	Dobutamine	2.5 to 5 mcg/kg/min, OR 5 to 20 mcg/kg/min
	Milrinone	0.125 to 0.75 mcg/kg/min
Vasodilators	Nitroglycerin	5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated	Max is 400mcg/min
	Nitroprusside	5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated	Max is 400mcg/min
	Nesiritide	2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion	Max of 0.03 mcg/kg/minute
Hydralazine and isosorbide dinitrate	Fixed-dose combination	37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily	75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
	Individual doses	Hydralazine: 25 to 50 mg 3 or 4 times daily Isosorbide dinitrate: 20 to 30 mg 3 or 4 times daily	Hydralazine: 300 mg daily in divided doses Isosorbide dinitrate: 120 mg daily in divided doses
Digoxin		Loading dose: PO- 10 to 15 mcg/kg (half the total loading dose initially, then 1/4th the loading dose every 6 to 8 hours two times), OR IV- 8 to 12 mcg/kg (half the total loading dose initially, then 1/4th the loading dose every 6 to 8 hours two times) Maintenance dose: PO- 3.4 to 5.1 mcg/kg/day once daily, OR IV- 2.4 to 3.6 mcg/kh/day once daily Drugs that increase the concentration of digoxin include amiodarone, quinidine and verapamil||

Do's

Acute Decompensated Heart Failure

• Differentiate systolic and diastolic heart failure among patients with ADHF in order to guide therapy:
  • Inotropic agents that increase contractility are not indicated as important for the patient with acute decompensated systolic heart failure.
  • While beta blocker initiation is relatively contraindicated in acute decompensated systolic heart failure, control of tachycardia is very useful in the patient with diastolic heart failure to prolong left ventricular filling time.
  • While the initiation of ACE inhibitors may not be recommended in acute decompensated systolic heart failure, ACE inhibition may be of benefit in acute decompensated diastolic heart failure.
• Rely on the patient's volume status to guide the aggressiveness of diuresis in ADHF.
• Continue chronic medications during acute decompensation in the following conditions:
  • ACE inhibitor: may be continued if the patient is hemodynamically stable without a rising creatinine or hyperkalemia
  • Beta blocker: may be continued in the absence of hypotension
  • Aldosterone antagonist: may be continued in the absence of hypotension, hyperkalemia, and impaired renal function

• Digoxin decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy and associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, 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 amiodarone, quinidine and verapamil.
• DVT prophylaxis unless contraindicated.
• Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.
• Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
• Convert all IV diuretic to oral forms in anticipation of discharge.
• Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .

Chronic Heart Failure

• Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of heart failure as defined by ACCF/AHA. These are primarily the class 1 recommendations. It involves the use of ACE inhibitors or (ARBs), beta blockers, aldosterone antagonists, and hydralazine/nitrate medications.
• Order an echocardiogram as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.

Don'ts

• Avoid, if possible, NSAIDs, sympathomimetics, tricyclic antidepressants, class I and III antiarrhythmics (except amiodarone), and nondihydropyridine calcium channel blockers (diltiazem, verapamil as they can be harmful in acute decompensated HF.
• Don't administer parenteral inotropes in normotensive patients with acute decompensated HF without evidence of decreased organ perfusion.
• Don't combine an ACEI, ARB, and aldosterone antagonist in patients with HFrEF unless otherwise indicated as this combination carries a risk of renal dysfunction 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.
• Don't use statins routinely without other indications.
• Don't administer K+- sparing diuretic e.g amiloride or triamterene with aldosterone antagonist due to the elevated risk of hyperkalemia.

References