2013 ACCF/AHA Guideline The Hospitalized Patient

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

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

Hospitalized Patients Presenting With Heart Failure (DO NOT EDIT)

Class I

"1. 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) "

"2. 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)."

"3. Patients with HF admitted with evidence of significant fluid overload should be promptly treated with intravenous loop diuretics to reduce morbidity. (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) "

"4. 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) "

"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. (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. (Level of Evidence: B) "

"16. 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) "

"17. 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) "

"18.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. The use of performance improvement systems and/or evidence-based systems of care is recommended in the hospital and early postdischarge outpatient setting to identify appropriate HF patients for GDMT, provide clinicians with useful reminders to advance GDMT, and assess the clinical response. (Level of Evidence: B) "

"19. 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 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.

"4. 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) "

"5. 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. 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 nesiritide may be considered an adjuvant to diuretics for relief of dyspnea in patients admitted with acutely decompensated HF. (Level of Evidence: A) "

"6. 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) "

Vote on and Suggest Revisions to the Current Guidelines

• The CHF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

External Links

• 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