Congestive heart failure AHA recommendations for hospitalized patient

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahmoud Sakr, M.D. [2] Edzel Lorraine Co, D.M.D., M.D. [3]

2022 AHA/ACC/HFSA Heart Failure Guideline/ 2013 ACC/AHA Guideline, 2009 ACC/AHA Focused Update and 2005 Guidelines for the Diagnosis and Management of Heart Failure in the Adult (DO NOT EDIT)

Hospitalized Patients Presenting With Heart Failure (DO NOT EDIT)

Class I

"1. The diagnosis of HF is primarily based on signs and symptoms derived from a thorough history and physical examination. Clinicians should determine the following: a. Adequacy of systemic perfusion; b. Volume status; c. The contribution of precipitating factors and/or comorbidities; d. If the HF is new onset or an exacerbation of chronic disease; and e. Whether it is associated with preserved ejection fraction. " " Chest radiographs, electrocardiogram, and echocardiography are key tests in this assessment. (Level of Evidence: C) "

"2. Measurement of BNP or N-terminal pro-B-type natriuretic peptide (NT-proBNP) is useful to support clinical judgment for the diagnosis of acutely decompensated HF, especially in the setting of uncertainty for the diagnosis .(Level of Evidence: A) "

"3. Measurement of BNP or N-terminal pro-B-type natriuretic peptide (NT-proBNP) and/or cardiac troponin is useful for establishing prognosis or disease severity in acutely decompensated HF.(Level of Evidence: A) "

"4. Acute coronary syndrome precipitating heart failure hospitalization should be promptly identified by electrocardiogram and cardiac troponin testing, and treated, as appropriate to the overall condition and prognosis of the patient. (Level of Evidence: C) "

"5. Common precipitating factors for acute HF should be considered during initial evaluation, as recognition of these conditions is critical to guide appropriate therapy: (Level of Evidence: C) " a. Nonadherence with medication regimen, sodium and/or fluid restriction; b. Acute myocardial ischemia; c. Uncorrected high blood pressure; d. AF and other arrhythmias; e. Recent addition of negative inotropic drugs (e.g., verapamil, nifedipine, diltiazem, beta blockers); f. Pulmonary emboli; g. Initiation of drugs that increase salt retention (e.g., steroids, thiazolidinediones, NSAIDs); h. Excessive alcohol or illicit drug use; i. Endocrine abnormalities (e.g., diabetes mellitus, hyperthyroidism, hypothyroidism) ; j. Concurrent Infections (e.g., pneumonia, viral illnesses); and k. Additional acute cardiovascular disorders (e.g., valve disease endocarditis, myopericarditis, aortic dissection)."

"6. Oxygen therapy should be administered to relieve symptoms related to hypoxemia. (Level of Evidence: C) "

"7. Whether the diagnosis of HF is new or chronic, patients who present with rapid decompensation and hypoperfusion associated with decreasing urine output and other manifestations of shock are critically ill and rapid intervention should be used to improve systemic perfusion. (Level of Evidence: C) "

"8. Patients admitted with HF and with evidence of significant fluid overload should be treated with intravenous loop diuretics. Therapy should begin in the emergency department or outpatient clinic without delay, as early intervention may be associated with better outcomes for patients hospitalized with decompensated HF. (Level of Evidence: B) If patients are already receiving loop diuretic therapy, the initial intravenous dose should equal or exceed their chronic oral daily dose. Urine output and signs and symptoms of congestion should be serially assessed, and diuretic dose should be titrated accordingly to relieve symptoms and to reduce extracellular fluid volume excess. (Level of Evidence: C) "

"9. Effect of HF treatment should be monitored with careful measurement of fluid intake and output; vital signs; body weight, determined at the same time each day; clinical signs (supine and standing) and symptoms of systemic perfusion and congestion. Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications. (Level of Evidence: C) "

"10. In patients with clinical evidence of hypotension associated with hypoperfusion and obvious evidence of elevated cardiac filling pressures (e.g., elevated jugular venous pressure; elevated pulmonary artery wedge pressure), intravenous inotropic or vasopressor drugs should be administered to maintain systemic perfusion and preserve end organ performance while more definitive therapy is considered. (Level of Evidence: C) "

"11. Invasive hemodynamic monitoring should be performed to guide therapy in patients who are in respiratory distress or with clinical evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment. (Level of Evidence: C) "

"12. In patients with HFrEF experiencing a symptomatic exacerbation of HF requiring hospitalization during chronic maintenance treatment with GDMT, it is recommended that GDMT be continued in the absence of hemodynamic instability or contraindications. (Level of Evidence: C) "

"13. In patients with reduced ejection fraction experiencing a symptomatic exacerbation of HF requiring hospitalization during chronic maintenance treatment with oral therapies known to improve outcomes, particularly ACE inhibitors or ARBs and beta blocker therapy, it is recommended that these therapies be continued in most patients in the absence of hemodynamic instability or contraindications. (Level of Evidence: C) "

"14. In patients hospitalized with HF with reduced ejection fraction not treated with oral therapies known to improve outcomes, particularly ACE inhibitors or ARBs and beta blocker therapy, initiation of these therapies is recommended in stable patients prior to hospital discharge. (Level of Evidence: B) "

"15. Initiation of beta blocker therapy is recommended after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotropic agents. Beta-blocker therapy should be initiated at a low dose and only in stable patients. Particular caution should be used when initiating beta blockers in patients who have required inotropes during their hospital course. (Level of Evidence: B) "

"16. In all patients hospitalized with HF, both with preserved and low ejection fraction, transition should be made from intravenous to oral diuretic therapy with careful attention to oral diuretic dosing and monitoring of electrolytes. With all medication changes, the patient should be monitored for supine and upright hypotension, worsening renal function and HF signs/symptoms. (Level of Evidence: C) "

"17. Throughout the hospitalization as appropriate, before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed: (Level of Evidence: B) a. Initiation of GDMT if not previously established and not contraindicated; b. Precipitant causes of HF, barriers to optimal care transitions, and limitations in postdischarge support; c. Assessment of volume status and supine/upright hypotension with adjustment of HF therapy as appropriate; d. Titration and optimization of chronic oral HF therapy; e. Assessment of renal function and electrolytes where appropriate; f. Assessment and management of comorbid conditions; g. Reinforcement of HF education, self-care, emergency plans, and need for adherence; and h. Consideration for palliative care or hospice care in selected patients."

"18. Postdischarge systems of care, if available, should be used to facilitate the transition to effective outpatient care for patients hospitalized with HF. (Level of Evidence: B) "

"19. A patient admitted to the hospital with decompensated HF should receive venous thromboembolism prophylaxis with an anticoagulant medication if the risk-benefit ratio is favorable.(Level of Evidence: B) "

"20. Multidisciplinary HF disease-management programs are recommended for patients at high risk for hospital readmission, to facilitate the implementation of GDMT, to address different barriers to behavioral change, and to reduce the risk of subsequent rehospitalization for HF. (Level of Evidence: B) "

Class III (No Benefit)

"1. Use of parenteral inotropes in normotensive patients with acute decompensated HF without evidence of decreased organ perfusion is not recommended. (Level of Evidence: B) "

"2. Routine use of invasive hemodynamic monitoring in normotensive patients with acute decompensated HF and congestion with symptomatic response to diuretics and vasodilators is not recommended. (Level of Evidence: B) "

Class IIa

"1. When patients present with acute HF and known or suspected acute myocardial ischemia due to occlusive coronary disease, especially when there are signs and symptoms of inadequate systemic perfusion, urgent cardiac catheterization and revascularization is reasonable where it is likely to prolong meaningful survival. (Level of Evidence: C) "

"2. Invasive hemodynamic monitoring can be useful for carefully selected patients with acute heart failure who have persistent symptoms despite empiric adjustment of standard therapies, and (Level of Evidence: C) " a. Whose fluid status, perfusion, or systemic or pulmonary vascular resistances are uncertain, b. Whose systolic pressure remains low, or is associated with symptoms, despite initial therapy, c. Whose renal function is worsening with therapy d. Who require parenteral vasoactive agents or e. Who may need consideration for advanced device therapy or transplantation.

"3. Ultrafiltration is reasonable for patients with refractory congestion not responding to medical therapy. (Level of Evidence: B) "

"4. When diuresis is inadequate to relieve symptoms, it is reasonable to intensify the diuretic regimen using either: (Level of Evidence: B) " a. Higher doses of loop diuretics.; or b. Addition of a second diuretic (e.g., thiazide).

"5. Scheduling an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge is reasonable. (Level of Evidence: B) "

"6. Use of clinical risk-prediction tools and/or biomarkers to identify patients at higher risk for postdischarge clinical events is reasonable. (Level of Evidence: B) "

Class IIb

"1. The usefulness of BNP or N-terminal pro-B-type natriuretic peptide (NT-proBNP)-guided therapy for acutely decompensated HF is not well established. (Level of Evidence: A) "

"2. Intravenous inotropic drugs such as dopamine, dobutamine or milrinone might be reasonable for those patients presenting with documented severe systolic dysfunction, low blood pressure and evidence of low cardiac output, with or without congestion, to maintain systemic perfusion and preserve end-organ performance. (Level of Evidence: C) "

"3. Low-dose dopamine infusion may be considered in addition to loop diuretic therapy to improve diuresis and better preserve renal function and renal blood flow. (Level of Evidence: B) "

"4. Ultrafiltration may be considered for patients with obvious volume overload to alleviate congestive symptoms and fluid weight. (Level of Evidence: B) "

"5. Ultrafiltration may be considered for patients with refractory congestion not responding to medical therapy. (Level of Evidence: C) "

"6. If symptomatic hypotension is absent, intravenous nitroglycerin, nitroprusside or nesiritide may be considered an adjuvant to diuretics for relief of dyspnea in patients admitted with acutely decompensated HF. (Level of Evidence: A) " (Level of Evidence: A) "

"7. In patients hospitalized with volume overload, including HF, who have persistent severe hyponatremia and are at risk for or having active cognitive symptoms despite water restriction and maximization of GDMT, vasopressin antagonists may be considered in the short term to improve serum sodium concentration in hypervolemic, hyponatremic states with either a V2 receptor selective or a nonselective vasopressin antagonist. (Level of Evidence: B) "

External Links

• 2013 ACCF/AHA Guideline for the Management of Heart Failure

• 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

• The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult