2013 ACCF/AHA Guideline The Hospitalized Patient

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

2013 ACCF/AHA Guideline/2009 ACC/AHA Focused Update and 2005 Guideline 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. 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. Concurrent Infections (e.g., pneumonia, viral illnesses); and k. Additional acute cardiovascular disorders (e.g., valve disease endocarditis, myopericarditis, aortic dissection)."

"3. Measurement of BNP or 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) "

"4. Measurement of BNP or NT-proBNP and/or cardiac troponin is useful for establishing prognosis or disease severity in acutely decompensated HF. (Level of Evidence: A) "

"5. Patients with suspected or new-onset HF, or those presenting with acute decompensated HF, should undergo a chest x-ray to assess heart size and pulmonary congestion and to detect alternative cardiac, pulmonary, and other diseases that may cause or contribute to the patient’s symptoms. (Level of Evidence: C) "

"6. A 2-dimensional echocardiogram with Doppler should be performed during initial evaluation of patients presenting with HF to assess ventricular function, size, wall thickness, wall motion, and valve function. (Level of Evidence: C) "

"7. Repeat measurement of EF and measurement of the severity of structural remodeling are useful to provide information in patients with HF who have had a significant change in clinical status; who have experienced or recovered from a clinical event; or who have received treatment, including GDMT, that might have had a significant effect on cardiac function; or who may be candidates for device therapy. (Level of Evidence: C) "

"8. Invasive hemodynamic monitoring with a pulmonary artery catheter should be performed to guide therapy in patients who have respiratory distress or 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 ) "

"9. 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) "

"10. 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) "

"11. 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) "

"12. 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) "

"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. 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) "

"15. 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) "

"16. 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."

"17. 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) "

"18. 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 IIa

"1. 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).

"2. 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) "

"3. 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 NT-proBNP-guided therapy for acutely decompensated HF is not well established. (Level of Evidence: A) "

"2. Measurement of other clinically available tests such as biomarkers of myocardial injury or fibrosis may be considered for additive risk stratification in patients with acutely decompensated HF. (Level of Evidence: C) "

"3. 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) "

"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) "

"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) "

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