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| ==Treatment of Acute Decompensation of Heart Failure==
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| {{ Family tree/start}} | | | colspan="2"| ACCF/AHA Stages || colspan="2"|New York Heart Association Classification |
| {{Family tree | | A01| | A01=<div style="float: left; text-align: left; width: 45em; padding:1em;">
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| '''Initial stabilization:''' <br>
| | |A || At high risk for heart failure (HF) but without structural heart disease or symptoms of HF || - || - |
| ❑ Assess the airway <br>
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| ❑ Position the patient upright at an angle of 45 degrees, with legs dangling off the bedside <br>
| | |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 heart failure (HF) |
| ❑ Check pulse oximetry <br>
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| ❑ If hypoxemia is present (Sa02 < 90% or Pa02 <60 mmHg), administer oxygen with/without noninvasive ventilation <br>
| | |rowspan="4"|C || rowspan="4"| Structural heart disease with prior or current symptoms of HF |
| ❑ Avoid IV morphine (may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms) <br>
| | | I ||No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF) |
| ❑ Ensure continuous cardiac monitoring <br>
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| ❑ Secure intravenous access with 18 gauge cannula <br>
| | | II ||Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF |
| ❑ Monitor vitals signs <br>
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| ❑ Monitor fluid intake and urine output <br><br>
| | | III ||Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF |
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| '''Assess congestion and perfusion:'''<br>
| | | IV ||Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest |
| '''''Congestion at rest''''' (dry vs. wet)<br>
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| ''"Wet" suggested by orthopnea, ↑JVP, rales, S3, pedal edema''<br>
| | |D || Refractory HF requiring specialized interventions|| IV ||Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest |
| '''''Low perfusion at rest (warm vs. cold)'''''<br>
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| ''"Cold" suggested by narrow pulse pressure, cool extremities, hypotension'' <br>
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| The patient is:<br>
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| ❑ Warm and dry, OR <br>
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| ❑ Warm and wet, OR <br>
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| ❑ Cold and dry, OR <br>
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| ❑ Cold and wet <br><br>
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| '''Admit for in-hospital treatment if:''' <br>
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| ❑ Hypotension and/or cardiogenic shock <br>
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| ❑ Poor end-organ perfusion (worsening renal function, cold clammy extremities, altered mental status) <br>
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| ❑ Hypoxemia (Sa02 <90%)<br>
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| ❑ Atrial fibrillation with a rapid ventricular response resulting in hypotension <br>
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| ❑ Presence of an underlying condition, such as acute coronary syndrome <br><br>
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| '''Identify precipitating factor and treat accordingly:''' <br>
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| ''For more details on the manegemtn, click on the disease to be transferred to the resident survival guide'' <br>
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| ❑ Myocardial infarction <br>
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| ❑ Myocarditis <br>
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| ❑ Renal failure <br>
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| ❑ Hypertensive crisis <br>
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| ❑ Non adherence to medications <br>
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| ❑ Worsening aortic stenosis <br>
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| ❑ Drugs (NSAIDS, thiazides, calcium channel blocker, beta blockers) <br>
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| ❑ Toxins (alcohol, anthracyclines) <br>
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| ❑ Atrial fibrillation <br>
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| : ''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''
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| : ''Consider cardioversion if the patient is in cardiogenic shock or if new onset atrial fibrillation is the clear precipitant of the hemodynamic decompensation''
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| ❑ COPD <br>
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| ❑ Pulmonary embolism <br>
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| ❑ Anemia <br>
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| ❑ Thyroid abnormalities <br>
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| ❑ Systemic infection <br><br>
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| '''Treat congestion and optimize volume status:''' <br>
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| '''''Diuretics''''' <br>
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| ❑ IV loop diuretics as intermittent boluses or continuous infusion (I-B) <br>
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| ❑ Already on loop diuretics: IV dose >= home PO dose (I-B) <br>
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| ❑ Serial assessment of fluid intake and output, vital signs, body weight (measured every day at the same time) and symptoms <br>
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| ❑ Adjust dose according to volume status (I-B) <br>
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| ❑ Daily electrolytes, BUN, creatinine (I-C) <br>
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| ❑ Persistent symptoms: Increase dose of IV loop diuretics (I-B) OR Add a second diuretics, such as thiazide (I-B) <br>
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| ❑ Consider low dose dopamine infusion for improved diuresis and renal blood flow (IIb-B) <br>
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| ❑ Consider renal replacement therapy/Ultrafiltration in obvious volume overload (IIb-B) <br>
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| '''''Venodilators'''''<br>
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| ❑ Consider IV nitroglycerin, nitroprusside, or nesiritide as add-on to diuretics to relieve dyspnea (IIb-A) <br><br>
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| '''Treat low perfusion:'''<br>
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| ❑ Inotropes <br><br>
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| '''VTE prevention:''' <br>
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| ❑ Anticoagulation in the absence of contraindications (I-B)<br><br>
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| '''Chronic medical therapy:''' <br>
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| ❑ Chronic HFrEF and hemodynamically stable: continue medical therapy <br>
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| ❑ Initiate beat blockers at a low dose in stable patients following optimization of volume status and D/C IV diuretics and inotropes (I-B) <br><br>
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| '''Management of hyponatremia:''' <br>
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| ❑ Water restriction <br>
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| ❑ Optimization of chronic home medications <br>
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| ❑ Persistent hyponatremia and risk of cognitive impairment: vasopressin antagonist for short term (hypervolemic) </div> }}
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| {{Family tree/end}}
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| ==Prevention of Heart Failure in Stage A and B==
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| {{Family tree/start}}
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| {{Family tree | | | A01 | | | | | | | | | | A01= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''What is the stage of heart failure (HF)?''' </div>}}
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| {{Family tree | |,|-|^|-|.| | }}
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| {{Family tree | B01 | | B02 | | B01= '''Stage A''' <br><div style="float: left; text-align: left; width: 25em; padding:1em;">''At high risk for HF but without structural heart disease or symptoms of HF'' </div>| B02= '''Stage B''' <br> <div style="float: left; text-align: left; width: 25em; padding:1em;">''Structural heart disease but without signs or symptoms of HF'' </div>}}
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| {{Family tree | |!| | | |!| | | | | }}
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| {{Family tree | C01 | | C02 | | | | C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">
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| ❑ Encourage healthy lifestyle and exercise <br>
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| ❑ Treat hypertension ( I-A) <br>
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| ❑ Treat dyslipidemia (I-A) <br>
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| ❑ Control obesity (I-C) <br>
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| ❑ Treat DM (I-C) <br>
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| ❑ Avoid tobacco (I-C) <br>
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| ❑ Avoid cardiotoxic agents (I-C) <br>
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| ❑ Administer ACE-I if HTN, DM, CVD, PAD <br> </div>
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| | C02=<div style="float: left; text-align: left; width: 25em; padding:1em;">
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| ❑ Encourage healthy lifestyle and exercise <br>
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| ❑ Treat hypertension (I-A) <br>
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| ❑ Treat dyslipidemia (I-A) <br>
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| ❑ Control obesity (I-C) <br>
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| ❑ Treat DM (I-C) <br>
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| ❑ Avoid tobacco (I-C) <br>
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| ❑ Avoid cardiotoxic agents (I-C)</div>}}
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| {{Family tree | | | | | |!| | | | | }}
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| {{Family tree | | | | | D01 | | | | D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">
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| '''Consider additional measures in selected patients:'''
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| ❑ 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) <br>
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| ❑ 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) <br>
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| ❑ Administer statins if history of MI or ACS to prevent symptoms (I-A) <br>
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| ❑ 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</div>}}
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| {{Family tree/end}}
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| ==Treatment of Heart Failure in Stage C and D==
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| {{Family tree/start}}
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| {{Family tree | | | | | A01 | | | | | | | | | | A01= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''What is the stage of heart failure (HF)?''' </div>}}
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| {{Family tree | |,|-|-|-|+|-|-|-|.| }}
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| {{Family tree | B01 | | B02 | | B03 | | | | B01= '''Stage C HFrEF'''<br><div style="float: left; text-align: left; width: 25em; padding:1em;">''Structural heart disease with prior or current symptoms of HF and reduced ejection fraction''</div>| B02= '''Stage C HFpEF''' <br> <div style="float: left; text-align: left; width: 25em; padding:1em;">''Structural heart disease with prior or current symptoms of HF and preserved ejection fraction'' </div>| B03= '''Stage D''' <br> <div style="float: left; text-align: left; width: 25em; padding:1em;">''Refractory HF requiring specialized interventions'' </div>}}
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| {{Family tree | |!| | | |!| | | |!| | | }}
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| {{Family tree | C01 | | C02 | | C03 | | C01= <div style="float: left; text-align: left; width: 25em; padding:1em;">
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| * Exercise training (I-A)
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| * Education for self-care (I-B)
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| * Sodium restriction if symptomatic (IIa-C)
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| * Cardiac rehabilitation in patients clinically stable (IIa-B)
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| * Treatment of HTN, dyslipidemia, obesity, DM
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| * Avoid tobacco (I-C)
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| * Avoid cardiotoxic agents
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| '''''Medical therapy:'''''
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| * Control systolic and diastolic blood pressure (I-B)
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| * Diuretics to decrease symptoms of congestion (I-C)
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| * Coronary revascularization in CAD and Sx (IIa-C)
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| * Treat concomitant Afib (IIa-C)
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| * BB, ACE-I, ARB for hypertension (IIa-C)
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| * ARB to decrease hospitalization (IIb-B) </div>
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| | C02= <div style="float: left; text-align: left; width: 25em; padding:1em;">
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| * Exercise training (I-A)
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| * Education for self-care (I-B)
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| * Sodium restriction if symptomatic (IIa-C)
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| * Cardiac rehabilitation in patients clinically stable (IIa-B)
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| * Treatment of HTN, dyslipidemia, obesity, DM
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| * Avoid tobacco (I-C)
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| * Avoid cardiotoxic agents
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| '''''Routine drugs:'''''
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| * ACE-I or ARB (decrease mortality by 17%) (I-A)
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| * PLUS
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| * Beta blockers (decrease mortality by 34%) (I-A)
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| ** Bisprolol
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| ** Carvedilol
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| ** Sustained release metoprolol succinate
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| PLUS
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| * Loop diuretics (for symptomatic volume overload; Class II-IV) (I-A)
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| PLUS
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| * Aldosterone antagonist
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| ** 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)
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| ** LVEF >=40% AND symptoms of HF or DM (I-B)
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| '''''Add-on drugs in selected patients:'''''
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| * 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)
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| * Contraindications to ACE-I or ARB (IIa-B)
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| * Digitalis: to decrease hospitalizations (IIa-B)
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| * NYHA class II–IV symptoms and HFrEF or HFpEF: Omega-3 polyunsaturated fatty acid supplementation (IIa-B)</div>
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| | C03=<div style="float: left; text-align: left; width: 25em; padding:1em;">
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| '''''Fluid restriction:'''''
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| * Restriction to 1.5 to 2 L/d particularly in case of hyponatremia (IIa-C)
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| '''''Inotropes'''''
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| * Temporary inotropes: in case of cardiogenic shock to maintain perfusion, awaiting definitive therapy or resolution of acute precipitating event (I-C), '''''OR'''''
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| * Continuous inotropes:
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| :* Bridge therapy in stage D HF refractory to medical therapy and device therapy among patients eligible/awaiting MCS or heart transplant (IIa-B)
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| :* Short-term, continuous intravenous inotropes to maintain perfusion among hospitalized, severe systolic dysfunction, low blood pressure and significantly decreased cardiac output (IIb-B)
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| :* 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)
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| '''''Mechanical circulatory support (MCS)'''''
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| * Temporary MCS in HFrEF awaiting definitive therapy or resolution of acute precipitating event (I-B)
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| * Temporary MCS HFrEF with severe hemodynamic compromise, as a bridge therapy to recovery or decision (I-B)
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| * 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)
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| '''''Cardiac transplantation'''''
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| * Refractory to medical therapy, device, and surgery (I-C) </div>}}
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| {{Family tree/end}}
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