2013 ACCF/AHA Guideline The Hospitalized Patient: Difference between revisions

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(/* Hospitalized Patients Presenting With Heart Failure (DO NOT EDIT) Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: ...)
(/* Hospitalized Patients Presenting With Heart Failure (DO NOT EDIT) Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: ...)
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:'''a.''' Higher doses of [[Congestive heart failure diuretics#Loop Diuretics|loop diuretics]]; or
:'''a.''' Higher doses of [[Congestive heart failure diuretics#Loop Diuretics|loop diuretics]]; or
:'''b.''' Addition of a second diuretic (e.g.,  [[Congestive heart failure diuretics#Thiazide Diuretics|thiazide]]).
:'''b.''' Addition of a second diuretic (e.g.,  [[Congestive heart failure diuretics#Thiazide Diuretics|thiazide]]).
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' 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 [[Congestive heart failure diuretics|diuretics]] and/or in those who do not respond to diuretics alone. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' [[Congestive heart failure invasive monitoring|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 ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' [[Congestive heart failure invasive monitoring|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 ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
:'''a.''' whose fluid status, perfusion, or systemic or pulmonary vascular resistances are uncertain,
:'''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,
:'''b.''' whose systolic pressure remains low, or is associated with symptoms, despite initial therapy,
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|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' 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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' 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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' [[Congestive heart failure ultrafiltration|Ultrafiltration]] may be considered for patients with obvious volume overload to alleviate congestive symptoms and fluid weight.'' ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' [[Congestive heart failure ultrafiltration|Ultrafiltration]] may be considered for patients with obvious volume overload to alleviate congestive symptoms and fluid weight.'' ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' [[Congestive heart failure ultrafiltration|Ultrafiltration]]  may be considered for patients with refractory congestion not responding to medical therapy.'' ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' [[Congestive heart failure ultrafiltration|Ultrafiltration]]  may be considered for patients with refractory congestion not responding to medical therapy.'' ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.''' If symptomatic [[hypotension]] is absent, intravenous [[nitroglycerin]], [[nitroprusside]] or [[nesiritide]]may be considered an adjuvant to [[Congestive heart failure diuretics|diuretics]] for relief of dyspnea in patients admitted with acutely decompensated HF. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
|}
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Revision as of 18:28, 8 August 2013
Resident
Survival
Guide
File:Physician Extender Algorithms.gif

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

Cardiac Catheterization

Other Imaging Studies

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
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Antiarrhythmic Drugs
Nutritional Supplements
Hormonal Therapies
Drugs to Avoid
Drug Interactions
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

2013 ACCF/AHA Guideline The Hospitalized Patient On the Web

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Classification of Acute Decompensated HF

2009 ACC/AHA Focused Update and 2005 Guidelines for the Diagnosis and Management of Chronic Heart Failure in the Adult (DO NOT EDIT) [1]

Hospitalized Patients Presenting With Heart Failure (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.[2][3] (Level of Evidence: A) "
"3. Acute coronary syndrome precipitating acute heart failure decompensation should be promptly identified by electrocardiogram and serum biomarkers, including cardiac troponin testing, and treated optimally as appropriate to the overall condition and prognosis of the patient. (Level of Evidence: C) "
"4. 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. ConcurrentInfections (e.g., pneumonia, viral illnesses); and
k. Additional acute cardiovascular disorders (e.g., valve disease endocarditis, myopericarditis, aortic dissection)."
"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 with HF admitted with evidence of significant fluid overload should be promptly treated with intravenous loop diuretics to reduce morbidity. [4][5][6] (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 and should be given as either intermittent boluses or continuous infusion. Urine output and signs and symptoms of congestion should be serially assessed, and the diuretic dose should be adjusted accordingly to relieve symptoms, reduce volume excess, and avoid hypotension. (Level of Evidence: B) "
"8. The effect of HF treatment should be monitored with careful measurement of fluid intake and output, vital signs, body weight that is determined at the same time each day, and clinical signs and symptoms of systemic perfusion and congestion. Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of intravenous diuretics or active titration of HF 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. 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 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: B) "
"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. [7][8] (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. Caution should be used when initiating beta blockers in patients who have required inotropes during their hospital course.[7][8] (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: "
a. Diet,
b. Discharge medications, with a special focus on adherence, persistence, and uptitration to recommended doses of ACE inhibitor/ARB and beta blocker medication,
c. Activity level,
d. Follow-up appointments,
e. Daily weight monitoring, and
f. 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. [9][10][11][12][13][14][15] (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. [16] (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. [17] (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. 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).
"3. 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.
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) "
"2. Low-dosedopamine 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) "
"3. Ultrafiltration may be considered for patients with obvious volume overload to alleviate congestive symptoms and fluid weight. (Level of Evidence: B) "
"4. Ultrafiltration may be considered for patients with refractory congestion not responding to medical therapy. (Level of Evidence: C) "
"5. If symptomatic hypotension is absent, intravenous nitroglycerin, nitroprusside or nesiritidemay be considered an adjuvant to diuretics for relief of dyspnea in patients admitted with acutely decompensated HF. (Level of Evidence: A) "

Vote on and Suggest Revisions to the Current Guidelines

External Links

References

  1. ↑ 1.0 1.1 1.2 Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 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. Circulation 119 (14):1977-2016. DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967
  2. ↑ Maisel AS, Krishnaswamy P, Nowak RM, McCord J, Hollander JE, Duc P, Omland T, Storrow AB, Abraham WT, Wu AH, Clopton P, Steg PG, Westheim A, Knudsen CW, Perez A, Kazanegra R, Herrmann HC, McCullough PA (2002). "Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure". The New England Journal of Medicine. 347 (3): 161–7. doi:10.1056/NEJMoa020233. PMID 12124404. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  3. ↑ Moe GW, Howlett J, Januzzi JL, Zowall H (2007). "N-terminal pro-B-type natriuretic peptide testing improves the management of patients with suspected acute heart failure: primary results of the Canadian prospective randomized multicenter IMPROVE-CHF study". Circulation. 115 (24): 3103–10. doi:10.1161/CIRCULATIONAHA.106.666255. PMID 17548729. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  4. ↑ Mebazaa A, Gheorghiade M, Piña IL, Harjola VP, Hollenberg SM, Follath F, Rhodes A, Plaisance P, Roland E, Nieminen M, Komajda M, Parkhomenko A, Masip J, Zannad F, Filippatos G (2008). "Practical recommendations for prehospital and early in-hospital management of patients presenting with acute heart failure syndromes". Critical Care Medicine. 36 (1 Suppl): S129–39. doi:10.1097/01.CCM.0000296274.51933.4C. PMID 18158472. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  5. ↑ Costanzo MR, Johannes RS, Pine M, Gupta V, Saltzberg M, Hay J, Yancy CW, Fonarow GC (2007). "The safety of intravenous diuretics alone versus diuretics plus parenteral vasoactive therapies in hospitalized patients with acutely decompensated heart failure: a propensity score and instrumental variable analysis using the Acutely Decompensated Heart Failure National Registry (ADHERE) database". American Heart Journal. 154 (2): 267–77. doi:10.1016/j.ahj.2007.04.033. PMID 17643575. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  6. ↑ Silvers SM, Howell JM, Kosowsky JM, Rokos IC, Jagoda AS (2007). "Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with acute heart failure syndromes". Annals of Emergency Medicine. 49 (5): 627–69. doi:10.1016/j.annemergmed.2006.10.024. PMID 17408803. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  7. ↑ 7.0 7.1 Metra M, Torp-Pedersen C, Cleland JG, Di Lenarda A, Komajda M, Remme WJ, Dei Cas L, Spark P, Swedberg K, Poole-Wilson PA (2007). "Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET". European Journal of Heart Failure. 9 (9): 901–9. doi:10.1016/j.ejheart.2007.05.011. PMID 17581778. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  8. ↑ 8.0 8.1 Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, O'Connor CM, Sun JL, Yancy CW, Young JB (2008). "Influence of beta-blocker continuation or withdrawal on outcomes in patients hospitalized with heart failure: findings from the OPTIMIZE-HF program". Journal of the American College of Cardiology. 52 (3): 190–9. doi:10.1016/j.jacc.2008.03.048. PMID 18617067. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  9. ↑ McAlister FA, Stewart S, Ferrua S, McMurray JJ (2004). "Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials". Journal of the American College of Cardiology. 44 (4): 810–9. doi:10.1016/j.jacc.2004.05.055. PMID 15312864. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  10. ↑ Lappé JM, Muhlestein JB, Lappé DL, Badger RS, Bair TL, Brockman R, French TK, Hofmann LC, Horne BD, Kralick-Goldberg S, Nicponski N, Orton JA, Pearson RR, Renlund DG, Rimmasch H, Roberts C, Anderson JL (2004). "Improvements in 1-year cardiovascular clinical outcomes associated with a hospital-based discharge medication program". Annals of Internal Medicine. 141 (6): 446–53. PMID 15381518. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  11. ↑ Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M (1994). "Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial". Annals of Internal Medicine. 120 (12): 999–1006. PMID 8185149. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  12. ↑ Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS (2004). "Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial". Journal of the American Geriatrics Society. 52 (5): 675–84. doi:10.1111/j.1532-5415.2004.52202.x. PMID 15086645. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  13. ↑ Windham BG, Bennett RG, Gottlieb S (2003). "Care management interventions for older patients with congestive heart failure". The American Journal of Managed Care. 9 (6): 447–59, quiz 460–1. PMID 12816174. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  14. ↑ Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR (2004). "Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis". JAMA : the Journal of the American Medical Association. 291 (11): 1358–67. doi:10.1001/jama.291.11.1358. PMID 15026403. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  15. ↑ Koelling TM, Johnson ML, Cody RJ, Aaronson KD (2005). "Discharge education improves clinical outcomes in patients with chronic heart failure". Circulation. 111 (2): 179–85. doi:10.1161/01.CIR.0000151811.53450.B8. PMID 15642765. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  16. ↑ Cuffe MS, Califf RM, Adams KF, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M (2002). "Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial". JAMA : the Journal of the American Medical Association. 287 (12): 1541–7. PMID 11911756. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  17. ↑ Binanay C, Califf RM, Hasselblad V, O'Connor CM, Shah MR, Sopko G, Stevenson LW, Francis GS, Leier CV, Miller LW (2005). "Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial". JAMA : the Journal of the American Medical Association. 294 (13): 1625–33. doi:10.1001/jama.294.13.1625. PMID 16204662. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  18. ↑ Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al. (2005) ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 112 (12):e154-235. DOI:10.1161/CIRCULATIONAHA.105.167586 PMID: 16160202

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