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| | ==Treatment of Acute Decompensation of Heart Failure== |
| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| | | | | | | | A01 | | | | | |A01=<div style="float: left; text-align: left; width: 25em; padding:1em;">
| | '''Initial stabilization:''' <br> |
| ❑ '''Assess the [[ECG|<span style="color:white;">ECG</span>]]'''<br> ❑ '''Order [[troponin|<span style="color:white;">troponins</span>]]''' <br> ❑ '''Perform a bedside [[echocardiography|<span style="color:white;">echocardiography</span>]] (if available)''' </div>}}
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| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| | | | | | | | |!| | | | }}
| | * Oxygen with/without noninvasive ventilation |
| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| | | | | | | | A00 | | | A00= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient fulfill the criteria of [[myocardial infarction|<span style="color:white;">myocardial infarction</span>]]?'''<br><br>
| | |
| ❑ Rise and/or fall of [[cardiac biomarker|<span style="color:white;">cardiac biomarker</span>]] (preferably [[troponin|<span style="color:white;">troponin</span>]])<br>
| | * Sit up and have legs dangling off the bedside |
| '''''PLUS at least of the following''''' <br> | | |
| ❑ Symptoms of ischemia <br>
| | * Morphine |
| ❑ New [[ST|<span style="color:white;">ST</span>]]-T wave changes or new [[LBBB|<span style="color:white;">LBBB</span>]] <br>
| | |
| : ''STEMI'' <br> | | '''Assess congestion and perfusion:'''<br> |
| :❑ [[ST elevation|<span style="color:white;">ST elevation</span>]] in at least 2 contiguous leads of 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3 and/or of 1 mm (0.1mV) in other contiguous chest leads or the limb leads, '''''OR''''' <br>
| | |
| :❑ [[ST interval#ST Depression|<span style="color:white;">ST depression</span>]] in at least two precordial leads V1-V4 (suggestive of [[posterior MI|<span style="color:white;">posterior MI</span>]]), '''''OR''''' <br>
| | * Warm and dry (outpatient treatment), OR |
| :❑ [[ST depression|<span style="color:white;">ST depression</span>]] in several leads plus [[ST elevation|<span style="color:white;">ST elevation</span>]] in lead aVR (suggestive of occlusion of the left main or proximal [[LAD|<span style="color:white;">LAD</span>]] artery) | | * Warm and wet (Diuresis +/- vasodilator), OR |
| : ''NSTEMI''
| | * Cold and dry (Admission to CCU: with/without inotropes), OR |
| :❑ [[ST depression|<span style="color:white;">ST depression</span>]] in at least 2 contiguous leads
| | * Cold and wet (Admission to CCU: diuresis, with/without inotropes) |
| ❑ New [[Q wave|<span style="color:white;">Q wave</span>]] <br>
| | |
| ❑ New regional wall abnormality or new myocardial loss </div>}}
| | '''Admit for in-hospital treatment if:''' <br> |
| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| | | | | | |,|-|^|-|.| | }}
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| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| | | | | | A10 | | A11 | A10 = Yes | A11= No}}
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| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| | | | | | |!| | | |!| | | }}
| | '''Identify precipitating factor and treat accordingly:''' <br> |
| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| | | | | | A12 | | A13 | | A12=<div style="float: left; text-align: left; padding:1em;">Activate cath lab team <br>
| | * Myocardial infarction |
| Click here for [[STEMI resident survival guide|<span style="color:white;">STEMI resident survival guide</span>]] <br> Click here for [[NSTEMI resident survival guide|<span style="color:white;">NSTEMI resident survival guide</span>]] </div>| A13=<div style="float: left; text-align: center; padding:1em;">'''Rule out the following life-threatening conditions''' </div>}}
| | * Myocarditis |
| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| | | | | | | | | | |!| | | }}
| | * Renal failure |
| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| | |,|-|-|-|v|-|-|-|+|-|-|-|-|-|-|-|.| | }}
| | * Hypertensive crisis |
| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| | C03 | | C04 | | C05 | | C06 | | C07 | C03= '''[[Pericarditis|<span style="color:white;">Pericarditis</span>]]''' | C04= '''[[Aortic dissection|<span style="color:white;">Aortic dissection</span>]]''' | C05= '''[[Pulmonary embolism|<span style="color:white;">Pulmonary embolism</span>]]'''| C06= '''[[Tension pneumothorax|<span style="color:white;">Tension pneumothorax</span>]]'''| C07= '''[[Esophageal rupture|<span style="color:white;">Esophageal rupture</span>]]'''}}
| | * Non adherence to medications |
| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| | |!| | | |!| | | |!| | | |!| | | |!| | }}
| | * Worsening aortic stenosis |
| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| | D03 | | D04 | | D05 | | D06 | | D07| D03=<div style="float: left; text-align: left; width: 12em; padding:1em;">
| | * Drugs (NSAIDS, thiazides, calcium channel blocker, beta blockers) |
| '''Look for supportive ECG changes:''' <br> ❑ Diffuse [[ST elevation|<span style="color:white;">ST elevation</span>]], '''''AND/OR'''''<br>
| | * Toxins (alcohol, anthracyclines) |
| ❑ PR depression, '''''AND/OR''''' <br>
| | * Arrhythmia |
| ❑ PR elevation in lead aVR
| | * COPD |
| <br>
| | * PE |
| '''Look for supportive signs and symptoms:''' <br> | | * Anemia |
| ❑ [[Pleuritic pain|<span style="color:white;">Pleuritic pain</span>]] <br>
| | * Thyroid abnormalities |
| ❑ [[Chest pain|<span style="color:white;">Chest pain</span>]] that is positional <br>
| | * Systemic infection |
| ❑ [[Viral infection|<span style="color:white;">Viral syndromes</span>]] <br>
| | |
| ❑ [[Fever|<span style="color:white;">Fever</span>]] <br>
| | |
| ❑ [[Cough|<span style="color:white;">Cough</span>]] <br>
| | '''Treat congestion and optimize volume status:''' <br> |
| ❑ [[Pericardial rub|<span style="color:white;">Pericardial rub</span>]]</div>
| | '''''Diuretics''''' <br> |
| | D04= <div style="float: left; text-align: left; padding:1em;"> '''Look for supportive signs and symptoms:''' <br>
| | |
| ❑ Sudden onset of chest pain radiated to the back or interscapular pain<br>
| | * IV loop diuretics as intermittent boluses or continuous infusion (I-B) |
| ❑ [[Back pain|<span style="color:white;">Back pain</span>]] <br>
| | * Already on loop diuretics: IV dose >= home PO dose (I-B) |
| ❑ [[Acute heart failure|<span style="color:white;">Acute heart failure</span>]] <br>
| | * Serial assessment of fluid intake and output, vital signs, body weight (measured every day at the same time) and symptoms |
| ❑ Low pitched early diastolic murmur best heard at the 2nd right intercostal space <br>
| | * Adjust dose according to volume status (I-B) |
| ❑ Asymmetric blood pressure in the upper extremities <br>
| | * Daily electrolytes, BUN, creatinine (I-C) |
| ❑ [[Coma|<span style="color:white;">Coma</span>]]<br>
| | * Persistent symptoms: Increase dose of IV loop diuretics (I-B) OR Add a second diuretics, such as thiazide (I-B) |
| ❑ Diminution or absence of pulse <br>
| | * Consider low dose dopamine infusion for improved diuresis and renal blood flow (IIb-B) |
| ❑ [[Altered mental status|<span style="color:white;">Altered mental status</span>]] <br>
| | * Consider renal replacement therapy/Ultrafiltration in obvious volume overload (IIb-B) |
| ❑ Vagal episode <br>
| | |
| ❑ Evidence of ischemia <br>
| | '''''Venodilators'''''<br> |
| :❑ Splanchnic ischemia <br>
| | |
| :❑ Renal insufficiency <br>
| | * Consider IV nitroglycerin, nitroprusside, or nesiritide as add-on to diuretics to relieve dyspnea (IIb-A) |
| :❑ Lower extremity ischemia <br>
| | |
| :❑ Focal neurologic deficits </div>
| | '''Treat low perfusion:'''<br> |
| | D05= <div style="float: left; text-align: left; padding:1em;"> '''Look for supportive signs and symptoms:''' <br>
| | |
| ❑ [[Pleuritic chest pain|<span style="color:white;">Pleuritic chest pain</span>]]
| | * Inotropes |
| ❑ [[Dyspnea|<span style="color:white;">Dyspnea</span>]] <br>
| | |
| ❑ [[Anxiety|<span style="color:white;">Anxiety</span>]] <br>
| | '''VTE prevention:''' |
| ❑ History of:<br>
| | * Anticoagulation in the absence of contraindications (I-B) |
| :❑ [[DVT|<span style="color:white;">DVT</span>]]
| | |
| :❑ Recent [[surgery|<span style="color:white;">surgery</span>]]
| | '''Chronic medical therapy:''' |
| :❑ [[Malignancy|<span style="color:white;">Malignancy</span>]]
| | |
| :❑ Immobility</div>
| | * Chronic HFrEF and hemodynamically stable: continue medical therapy |
| | D06= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br>
| | * Initiate beat blockers at a low dose in stable patients following optimization of volume status and D/C IV diuretics and inotropes (I-B) |
| ❑ Sudden [[shortness of breath|<span style="color:white;">Shortness of breath</span>]] <br>
| | |
| ❑ [[Cyanosis|<span style="color:white;">Cyanosis</span>]] <br>
| | '''Management of hyponatremia:''' |
| ❑ [[Penetrating chest wound|<span style="color:white;">Penetrating chest wound</span>]] <br>
| | |
| ❑ Flopping sound <br>
| | * Water restriction |
| ❑ Recent medical procedure <br>
| | * Optimization of chronic home medications |
| ❑ Patient on [[mechanical ventilation|<span style="color:white;">mechanical ventilation</span>]] <br>
| | * Persistent hyponatremia and risk of cognitive impairment: vasopressin antagonist for short term (hypervolemic) |
| ❑ Tracheal deviation towards the unaffected side<br>
| |
| ❑ Absent heart sound on the affected side <br>
| |
| ❑ Hyperresonance on the affected side </div>
| |
| | D07=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br>
| |
| ❑ [[Vomiting|<span style="color:white;">Vomiting</span>]] <br>
| |
| ❑ Lower [[chest pain|<span style="color:white;">chest pain</span>]] <br>
| |
| ❑ [[Hematemesis|<span style="color:white;">Hematemesis</span>]] <br>
| |
| ❑ Cervical [[subcutaneous emphysema|<span style="color:white;">subcutaneous emphysema</span>]] <br>
| |
| ❑ Overindulgence in alcohol <br>
| |
| ❑ Overindulgence in food </div>}}
| |
| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| | |!| | | |!| | | |!| | | |!| | | |!| }}
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| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF;| | E02 | | E04 | | E05 | | E06 | | E07 | E02= [[Pericarditis resident survival guide|<span style="color:white;">Click here for the detailed management</span>]]| E04= [[Aortic dissection resident survival guide|<span style="color:white;">Click here for the detailed management</span>]]| E05= [[Pulmonary embolism resident survival guide|<span style="color:white;">Click here for the detailed management</span>]]| E06= [[Tension pneumothorax resident survival guide|<span style="color:white;">Click here for the detailed management</span>]]| E07= [[Esophageal rupture resident survival guide|<span style="color:white;">Click here for the detailed management</span>]]}}
| |
| {{familytree/end}}
| |
Treatment of Acute Decompensation of Heart Failure
Initial stabilization:
- Oxygen with/without noninvasive ventilation
- Sit up and have legs dangling off the bedside
Assess congestion and perfusion:
- Warm and dry (outpatient treatment), OR
- Warm and wet (Diuresis +/- vasodilator), OR
- Cold and dry (Admission to CCU: with/without inotropes), OR
- Cold and wet (Admission to CCU: diuresis, with/without inotropes)
Admit for in-hospital treatment if:
Identify precipitating factor and treat accordingly:
- 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)
- Arrhythmia
- COPD
- PE
- 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:
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)