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===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]===
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|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:
'''1.''' The diagnosis of [[heart failure]] is primarily based on signs and symptoms derived from a thorough [[Congestive heart failure history and symptoms|history]] and [[Congestive heart failure physical examination|physical examination]]. Clinicians should determine the following:
:'''a.''' adequacy of systemic perfusion;
:'''a.''' adequacy of systemic perfusion;
:'''b.''' volume status;
:'''b.''' volume status;
:'''c.''' the contribution of precipitating factors and/or comorbidities;
:'''c.''' the contribution of precipitating factors and/or comorbidities;
:'''d.''' if the heart failure is new onset or an exacerbation of chronic disease; and
:'''d.''' if the [[heart failure]] is new onset or an exacerbation of chronic disease; and
:'''e.''' whether it is associated with preserved ejection fraction.
:'''e.''' whether it is associated with preserved [[ejection fraction]].


Chest radiographs, electrocardiogram, and echocardiography are key tests in this assessment. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
[[Congestive heart failure chest x ray|Chest radiographs]], [[Congestive heart failure electrocardiogram|electrocardiogram]], and [[Congestive heart failure echocardiography|echocardiography]] are key tests in this assessment. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


'''2.''' Concentrations of [[BNP|B-type natriuretic peptide]] ([[BNP]]) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) should be measured in patients being evaluated for [[dyspnea]] in which the contribution of HF is not known. Final diagnosis requires interpreting these results in the context of all available clinical data and ought not to be considered a stand alone test. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
'''2.''' Concentrations of [[BNP|B-type natriuretic peptide]] ([[BNP]]) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) should be measured in patients being evaluated for [[dyspnea]] in which the contribution of [[heart failure]] is not known. Final diagnosis requires interpreting these results in the context of all available clinical data and ought not to be considered a stand alone test. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''


'''3.''' [[Acute coronary syndrome]] precipitating [[HF]] hospitalization should be promptly identified by electrocardiogram and cardiac troponin testing, and treated, as appropriate to the overall condition and prognosis of the patient. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
'''3.''' [[Acute coronary syndrome]] precipitating [[heart failure]] hospitalization should be promptly identified by [[Congestive heart failure electrocardiogram|electrocardiogram]] and [[Troponin#Diagnostic Use|cardiac troponin testing]], and treated, as appropriate to the overall condition and prognosis of the patient. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


'''4.''' It is recommended that the following common potential precipitating factors for [[HF|acute HF be]] identified as recognition of these comorbidities is critical to guide therapy: ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
'''4.''' It is recommended that the following common potential precipitating factors for [[HF|acute HF]] be identified as recognition of these comorbidities is critical to guide therapy: ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
:'''a.''' [[acute coronary syndromes]]/[[ischemia|coronary ischemia]];
:'''a.''' [[acute coronary syndromes]]/[[ischemia|coronary ischemia]];
:'''b.''' severe [[hypertension]];
:'''b.''' severe [[hypertension]];
:'''c.''' atrial and ventricular arrhythmias;
:'''c.''' [[atrial arrhythmias|atrial]] and [[ventricular arrhythmias]];
:'''d.''' infections;
:'''d.''' infections;
:'''e.''' [[pulmonary emboli]];
:'''e.''' [[pulmonary emboli]];
Line 46: Line 46:
'''5.''' Oxygen therapy should be administered to relieve symptoms related to [[hypoxemia]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
'''5.''' Oxygen therapy should be administered to relieve symptoms related to [[hypoxemia]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


'''6.''' 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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
'''6.''' Whether the diagnosis of [[heart failure]] 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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


'''7.''' 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]].''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' If patients are already receiving [[loop diuretics|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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
'''7.''' Patients admitted with [[heart failure]] and with evidence of significant [[fluid overload]] should be treated with intravenous [[Congestive heart failure diuretics|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 [[heart failure]].''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' If patients are already receiving [[Congestive heart failure diuretics|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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


'''8.''' 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 [[HF]] medications. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
'''8.''' Effect of [[heart failure]] 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 [[electrolytes|serum electrolytes]], [[urea nitrogen]], and [[creatinine]] concentrations should be measured during the use of [[Congestive heart failure diuretics|IV diuretics]] or active titration of [[heart failure]] medications. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


'''9.''' When diuresis is inadequate to relieve congestion, as evidenced by clinical evaluation, the diuretic regimen should be intensified using either: ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
'''9.''' When [[diuresis]] is inadequate to relieve congestion, as evidenced by clinical evaluation, the diuretic regimen should be intensified using either: ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
:'''a.''' higher doses of [[loop diuretics]];
:'''a.''' higher doses of [[Congestive heart failure diuretics#Loop Diuretics|loop diuretics]];
:'''b.''' addition of a second diuretic (such as [[metolazone]], [[spironolactone]] or intravenous [[chlorothiazide]]); or
:'''b.''' addition of a second diuretic (such as [[Congestive heart failure aldosterone antagonists|metolazone]], [[Congestive heart failure aldosterone antagonists|spironolactone]] or intravenous [[Congestive heart failure diuretics#Thiazide Diuretics|chlorothiazide]]); or
:'''c.''' continuous infusion of a loop diuretic.  
:'''c.''' continuous infusion of a [[Congestive heart failure diuretics#Loop Diuretics|loop diuretic]].  


'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|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 capillary wedge pressure|pulmonary artery wedge pressure]]), intravenous [[Congestive heart failure positive inotropics|inotropic or vasopressor drugs]] should be administered to maintain systemic perfusion and preserve end organ performance while more definitive therapy is considered. ''([[ACC AHA guidelines classification scheme#Level of Evidence|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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
'''11.''' [[Congestive heart failure invasive monitoring|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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


'''12.''' Medications should be reconciled in every patient and adjusted as appropriate on admission to and discharge from the hospital. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
'''12.''' Medications should be reconciled in every patient and adjusted as appropriate on admission to and discharge from the hospital. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


'''13.''' In patients with [[EF|reduced ejection fraction]] experiencing a symptomatic exacerbation of [[HF]] requiring hospitalization during chronic maintenance treatment with oral therapies known to improve outcomes, particularly [[ACEI|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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
'''13.''' In patients with [[EF|reduced ejection fraction]] experiencing a symptomatic exacerbation of [[heart failure]] requiring hospitalization during chronic maintenance treatment with oral therapies known to improve outcomes, particularly [[Congestive heart failure ACE inhibitors or angiotensin receptor blockers|ACE inhibitors]] or [[Congestive heart failure ACE inhibitors or angiotensin receptor blockers|ARBs]] and [[Congestive heart failure beta blockers|beta blocker therapy]], it is recommended that these therapies be continued in most patients in the absence of hemodynamic instability or contraindications. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


'''14.''' In patients hospitalized with [[HF]] with [[EF|reduced ejection fraction]] not treated with oral therapies known to improve outcomes, particularly [[ACEI|ACE inhibitors]] or [[ARBs]] and [[beta blocker]] therapy, initiation of these therapies is recommended in stable patients prior to hospital discharge.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
'''14.''' In patients hospitalized with [[heart failure]] with [[EF|reduced ejection fraction]] not treated with oral therapies known to improve outcomes, particularly [[Congestive heart failure ACE inhibitors or angiotensin receptor blockers|ACE inhibitors]] or [[Congestive heart failure ACE inhibitors or angiotensin receptor blockers|ARBs]] and [[Congestive heart failure beta blockers|beta blocker therapy]], initiation of these therapies is recommended in stable patients prior to hospital discharge.''([[ACC AHA guidelines classification scheme#Level of Evidence|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
'''15.''' Initiation of [[Congestive heart failure beta blockers|beta blocker therapy]] is recommended after optimization of volume status and successful discontinuation of intravenous [[Congestive heart failure diuretics|diuretics]], [[Congestive heart failure vasodilators|vasodilators]], and [[Congestive heart failure positive inotropics|inotropic agents]]. [[Congestive heart failure beta blockers|Beta-blocker therapy]] should be initiated at a low dose and only in stable patients. Particular caution should be used when initiating [[Congestive heart failure beta blockers|beta blockers]] in patients who have required [[Congestive heart failure positive inotropics|inotropes]] during their hospital course. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
patients. Particular caution should be used when initiating beta blockers in patients who have required inotropes during their hospital course. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''


'''16.''' In all patients hospitalized with [[HF]], both with preserved and low [[EF]], 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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
'''16.''' In all patients hospitalized with [[heart failure]], both with preserved and low [[ejection fraction]], transition should be made from intravenous to oral [[Congestive heart failure diuretics|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]], [[renal dysfunction|worsening renal function]] and [[heart failure]] [[Congestive heart failure physical examination|signs]]/[[Congestive heart failure history and symptoms|symptoms]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


'''17.''' Comprehensive written discharge instructions for all patients with a hospitalization for [[HF]] and their caregivers is strongly recommended, with special emphasis on the following 6 aspects of care: diet, discharge medications, with a special focus on adherence, persistence, and uptitration to recommended doses of ACE inhibitor/ARB and [[beta blocker]] medication, activity level, follow-up appointments, daily weight monitoring, and what to do if [[HF]] symptoms worsen. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
'''17.''' Comprehensive written discharge instructions for all patients with a hospitalization for [[heart failure]] and their caregivers is strongly recommended, with special emphasis on the following 6 aspects of care: diet, discharge medications, with a special focus on adherence, persistence, and uptitration to recommended doses of [[Congestive heart failure ACE inhibitors or angiotensin receptor blockers|ACE inhibitor]]/[[Congestive heart failure ACE inhibitors or angiotensin receptor blockers|ARB]] and [[Congestive heart failure beta blockers|beta blocker]] medication, activity level, follow-up appointments, daily weight monitoring, and what to do if [[heart failure]] symptoms worsen. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


'''18.''' Postdischarge systems of care, if available, should be used to facilitate the transition to effective outpatient care for patients hospitalized with [[HF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
'''18.''' Postdischarge systems of care, if available, should be used to facilitate the transition to effective outpatient care for patients hospitalized with [[heart failure]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''


===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]===
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]===
'''1.''' When patients present with acute [[HF]] and known or suspected [[MI|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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
'''1.''' When patients present with acute [[heart failure]] and known or suspected [[MI|acute myocardial ischemia]] due to occlusive coronary disease, especially when there are signs and symptoms of inadequate systemic perfusion, urgent [[Congestive heart failure cardiac catheterization|cardiac catheterization]] and revascularization is reasonable where it is likely to prolong meaningful survival. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


'''2.''' In patients with evidence of severely symptomatic fluid overload in the absence of systemic [[hypotension]], [[vasodilators]] such as intravenous [[nitroglycerin]], [[nitroprusside]] or [[nesiritide]] can be beneficial when added to [[diuretics]] and/or in those who do not respond to diuretics alone. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
'''2.''' In patients with evidence of severely symptomatic [[fluid overload]] in the absence of systemic [[hypotension]], [[Congestive heart failure vasodilators|vasodilators]] such as intravenous [[nitroglycerin]], [[nitroprusside]] or [[nesiritide]] can be beneficial when added to [[diuretics]] and/or in those who do not respond to diuretics alone. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


'''3.''' Invasive hemodynamic monitoring can be useful for carefully selected patients with acute [[HF]] who have persistent symptoms despite empiric adjustment of standard therapies, and ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
'''3.''' Invasive hemodynamic monitoring can be useful for carefully selected patients with acute [[HF]] who have persistent symptoms despite empiric adjustment of standard therapies, and ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''

Revision as of 15:27, 6 April 2012

Heart failure
ICD-10 I50.0
ICD-9 428.0
DiseasesDB 16209
MedlinePlus 000158
MeSH D006333
Congestive Heart Failure Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Systolic Dysfunction
Diastolic Dysfunction
HFpEF
HFrEF

Causes

Differentiating Congestive heart failure from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Clinical Assessment

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

Cardiac MRI

Echocardiography

Exercise Stress Test

Myocardial Viability Studies

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Other Diagnostic Studies

Treatment

Invasive Hemodynamic Monitoring

Medical Therapy:

Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF
Diuretics
ACE Inhibitors
Angiotensin receptor blockers
Aldosterone Antagonists
Beta Blockers
Ca Channel Blockers
Nitrates
Hydralazine
Positive Inotropics
Anticoagulants
Angiotensin Receptor-Neprilysin Inhibitor
Antiarrhythmic Drugs
Nutritional Supplements
Hormonal Therapies
Drugs to Avoid
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Treatment of underlying causes
Associated conditions

Exercise Training

Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Ultrafiltration
Cardiac Surgery
Left Ventricular Assist Devices (LVADs)
Cardiac Transplantation

ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

Congestive heart failure AHA recommendations for hospitalized patient On the Web

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Risk calculators and risk factors for Congestive heart failure AHA recommendations for hospitalized patient

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

Overview

ACC/AHA Guidelines- For the Hospitalized Patient (DO NOT EDIT) [1]

Class I

1. The diagnosis of heart failure 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 heart failure 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. Concentrations of B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) should be measured in patients being evaluated for dyspnea in which the contribution of heart failure is not known. Final diagnosis requires interpreting these results in the context of all available clinical data and ought not to be considered a stand alone test. (Level of Evidence: A)

3. 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)

4. It is recommended that the following common potential precipitating factors for acute HF be identified as recognition of these comorbidities is critical to guide therapy: (Level of Evidence: C)

a. acute coronary syndromes/coronary ischemia;
b. severe hypertension;
c. atrial and ventricular arrhythmias;
d. infections;
e. pulmonary emboli;
f. renal failure; and
g. medical or dietary noncompliance.

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

6. Whether the diagnosis of heart failure 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)

7. Patients admitted with heart failure 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 heart failure.(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)

8. Effect of heart failure 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)

9. When diuresis is inadequate to relieve congestion, as evidenced by clinical evaluation, the diuretic regimen should be intensified using either: (Level of Evidence: C)

a. higher doses of loop diuretics;
b. addition of a second diuretic (such as metolazone, spironolactone or intravenous chlorothiazide); or
c. continuous infusion of a loop diuretic.

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. Medications should be reconciled in every patient and adjusted as appropriate on admission to and discharge from the hospital. (Level of Evidence: C)

13. In patients with reduced ejection fraction experiencing a symptomatic exacerbation of heart failure 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 heart failure 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 heart failure, 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 heart failure signs/symptoms. (Level of Evidence: C)

17. Comprehensive written discharge instructions for all patients with a hospitalization for heart failure and their caregivers is strongly recommended, with special emphasis on the following 6 aspects of care: diet, discharge medications, with a special focus on adherence, persistence, and uptitration to recommended doses of ACE inhibitor/ARB and beta blocker medication, activity level, follow-up appointments, daily weight monitoring, and what to do if heart failure symptoms worsen. (Level of Evidence: C)

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

Class IIa

1. When patients present with acute heart failure 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. In patients with evidence of severely symptomatic fluid overload in the absence of systemic hypotension, vasodilators such as intravenous nitroglycerin, nitroprusside or nesiritide can be beneficial when added to diuretics and/or in those who do not respond to diuretics alone. (Level of Evidence: C)

3. Invasive hemodynamic monitoring can be useful for carefully selected patients with acute HF 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.

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

Class IIb

1. 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)

Class III

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)

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