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CHF

 
 
 
 
 
 
 
 
 
 
 
 
 
 

Diuretic therapy

 

ACE inhibitors AND Beta blockers

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Intolerant to ACE-I

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Cough

 

Renal insufficiency or angioedema

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

ARBs

 

Hydralazine/isosorbide dinitrate[1]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Persistent symptoms?

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Yes

 

No

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Add:

❑ Aldosterone or eplerenone if:

❑ Cr ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women
❑ Estimated glomerular filtration rate >30 mL/min/1.73 m2
❑ Serum potassium ≤ 5.0 mEq/L
❑ NYHA class II–IV HF with LVEF ≤ 35%
OR

❑ Hydralazine/isosorbide dinitrate

❑ African Americans with NYHA class III–IV HFrEF on GDMT
OR

❑ ARBs[2]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Persistent symptoms?

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Add digoxin

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Persistent symptoms?

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Yes

 

No

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ LVEF ≤ 35%
❑ Sinus rhythm or LBBB

❑ NYHA III - IV
 
 
 
 
 

LVEF ≤ 35%?

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Yes

 

No

 

Yes

 

No

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Cardiac resynchronization therapy (CRT)
± Implantable cardioverter defibrillator (ICD)

 
 
 
 
 
 
Implantable cardioverter defibrillator

❑ As primary prevention of sudden cardiac death in:

❑ Post MI with LVEF ≤ 35%, NYHA II or III on chronic GDMT
❑ Post MI with LVEF ≤ 30%, NYHA I on chronic GDMT
 

Continue GDMT

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Persistent symptoms
(Advanced heart failure)

 
 
 
 
 
 
 
 
 
 
 

IV inotropes or vasodilators

 
 
 
 
 
 
 
 
 
 
Mechanical circulatory support (MCS)[3]:

❑ General indications:

❑ LVEF ≤ 25%
❑ NYHA III or IV on chronic GDMT
❑ Predicted 1-2 year mortality
 
 
 
 
 
 
 
 
 

Cardiac transplantation

Hypertension

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Warm & Dry

❑ Consider outpatient treatment
❑ Dietary sodium restriction (2-3 g daily)
❑ Smoking cessation
❑ Alcohol abstinence (≤2 standard drinks per day for men; ≤1 for women)
❑ Encourage exercise/physical activity

Although ACE inhibitors and beta blockers should not be administered to patients with acute decompensated heart failure, if the patient is compensated in the outpatient setting then administer:
❑ ACE inhibitors or (ARBs) if LVEF is ≤ 40%
❑ Beta blockers[6]
 
Warm & Wet

❑ Diuretic therapy

❑ Treat co-morbidities HTN, DM, CAD, AF
 
 
 
Cold & Wet

❑ CCU admission
❑ Invasive hemodynamic monitoring (arterial line, consider pulmonary catheter if volume status unclear)

❑ Intravenous inotropic drugs (e.g., dobutamine)
❑ Diuretic therapy while monitoring blood pressure
❑ IV vasodilators
 
Cold & Dry

❑ CCU admission
❑ Intravenous inotropic drugs (e.g., dobutamine)
❑ Persistent organ hypoperfusion (e.g., low urine output or persistent low SBP<85)

❑ Norepinephrine 0.2–1.0 mcg/kg/min, titrate to maintain a blood pressure of
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Indications for implantable cardioverter defibrillator (ICD)

❑ As primary prevention of sudden cardiac death in:

❑ Post MI with LVEF ≤ 35%, NYHA II or III on chronic GDMT (Class I, level of evidence A)
❑ Post MI with LVEF ≤ 30%, NYHA I on chronic GDMT (Class I, level of evidence B)
❑ Nonischemic dilated cardiomyopathy with LVEF ≤ 35% and NYHA II or III

Contraindications
❑ No reasonable expectation of survival with an acceptable functional status for at least 1 year
❑ Incessant ventriculat tachycardia or ventricular fibrillation
❑ Significant psychiatric illnesses that may be aggravated by device or that may preclude follow-up
❑ NYHA class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or cardiac resynchronization therapy

❑ Ventricular tachycardia due to completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
General measures

❑ Low sodium diet
❑ Monitor blood pressure, congestion, oxygenation
❑ Daily weights using same scale after 1st void at same time of day
❑ Intake and output charts
❑ Convert all IV diuretic to oral forms in anticipation of discharge
❑ Continue or initiate

❑ ACE inhibitors
❑ Beta blockers
❑ Omega-3 fatty acid[7]

❑ Daily serum electrolytes, urea & creatinine
❑ DVT prophylaxis
❑ Influenza & pneumococcal vaccination

❑ Encourage physical activity in stable patients
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Discharge and follow-Up

❑ Patient and family education
❑ Prior to discharge, ensure:

❑ Low salt diet
❑ Oral medication plan is stable for 24 hours
❑ No IV vasodilator or inotropic drugs for 24 hours
❑ Weighing scale is present in patient's home
❑ Smoking cessation counseling
❑ Follow-up clinic visit scheduled within 7 to 10 days
❑ Ambulation prior to discharge to assess functional capacity

❑ Telephone follow-up call usually 3 days post discharge
❑ Potassium monitoring and repletion

Click here for the detailed management of hyperkalemia and hypokalemia
 
 
 

Underlying Anatomic Abnormalities Causing Heart Failure

Heart failure may result from an abnormality of any one of the anatomical structures of the heart:

Systolic versus Diastolic Heart Failure

Patients may be broadly classified as having heart failure with depressed contractility or depressed relaxation

Systolic Dysfunction

The left ventricular ejection fraction is reduced in systolic dysfunction and there is depressed contractility of the heart.

Disastolic Dysfunciton

The left ventricular ejection fraction is preserved in diastolic dysfunction and there is an abnormality in myocardial relaxation or excessive myocardial stiffness. Systolic and diastolic dysfunction commonly occur in conjunction with each other.

Left, Right and Biventricular Failure

Another common method of classifying heart failure is based upon the ventricle involved (left sided versus right sided).

Left Heart Failure

  • There is impaired left ventricular function with reduced flow into the aorta.

Right Heart Failure

  • There is impaired right ventricular function with reduced flow into the pulmonary artery and lungs.

Biventricular Failure

  • The most common cause of right heart failure is left heart failure, and mixed presentations are common, especially when the cardiac septum is involved.

High Output Versus Low Output Failure

Low Output Failure

High Output Failure

Causes of Acute or Decompensated Heart Failure

Chronic stable heart failure may easily decompensate. This most commonly results from an intercurrent illness (such as pneumonia), myocardial infarction (a heart attack), arrhythmias, uncontrolled hypertension, or a patient's failure to maintain a fluid restriction, diet, or medication.[9] Other well recognized precipitating factors include anemia and hyperthyroidism which place additional strain on the heart muscle. Excessive fluid or salt intake, and medication that causes fluid retention such as NSAIDs and thiazolidinediones, may also precipitate decompensation.[10]

Differential Diagnosis of the Underlying Causes of Chronic Heart Failure

Common Causes of Left Sided Heart Failure

A 19 year study of 13,000 healthy adults in the United States (the National Health and Nutrition Examination Survey (NHANES I) found the following causes ranked by Population Attributable Risk score:[11]

  1. Ischaemic heart disease 62%
  2. Cigarette smoking 16%
  3. Hypertension (high blood pressure)10%
  4. Obesity 8%
  5. Diabetes 3%
  6. Valvular heart disease 2% (much higher in older populations)

Cardiomyopathies and Inflammatory Diseases

Restrictive Cardiomyopathies
Dilated Cardiomyopathies
Inflammatory Cardiomyopathies

Congestive Heart Failure as a Consequence of Valvular Heart Disease

Congestive Hert Failure Secondary to Congenital Heart Disease

A. Causes of Congestive Heart Failure in Adults with Unoperated Congenital Heart Diseases

B. Causes of Congestive Heart Failure in Adults with Operated Congenital Heart Diseases

Right Ventricular Failure

Factors affected right ventricle and to be eliminated during management of congestive heart failure. A. Right ventricular myocardial dysfunction

  1. Right ventricular myocardial infarction
  2. Dilated cardiomyopathy
  3. Right ventricular dysplasia

B. Primary right ventricular pressure overload

  1. Left ventricular failure
  2. Mitral valve disease
  3. Atrial myxoma
  4. Pulmonary veno-occlusive disease
  5. Cor pulmonale
  6. Pulmonic stenosis
  7. Ventricular septal defect
  8. Aortopulmonary communication

C. Primary right ventricular volume overload

  1. Pulmonic regurgitation
  2. Tricuspid regurgitation
  3. Atrial septal defect
  4. Partial anomalous pulmonary venous return

D. Impediment to right ventricular inflow

  1. Tricuspid stenosis
  2. Cardiac tamponade
  3. Constrictive pericarditis
  4. Restrictive cardiomyopathy

Differential Diagnosis of Causes of Heart Failure Segregated by Left and Right Sided Heart Failure

Left Ventricular Failure

Most Common Causes:

Expanded List of Causes:

Right Ventricular Failure

Most Common Causes:

Other Causes:

Others

  1. ↑ Cohn JN, Archibald DG, Ziesche S, Franciosa JA, Harston WE, Tristani FE; et al. (1986). "Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative Study". N Engl J Med. 314 (24): 1547–52. doi:10.1056/NEJM198606123142404. PMID 3520315.
  2. ↑ Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, Michelson EL; et al. (2003). "Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme". Lancet. 362 (9386): 759–66. PMID 13678868. Review in: ACP J Club. 2004 Mar-Apr;140(2):32-3
  3. ↑ Naidu SS (2011). "Novel percutaneous cardiac assist devices: the science of and indications for hemodynamic support". Circulation. 123 (5): 533–43. doi:10.1161/CIRCULATIONAHA.110.945055. PMID 21300961.
  4. ↑ Birks EJ, Tansley PD, Hardy J, George RS, Bowles CT, Burke M; et al. (2006). "Left ventricular assist device and drug therapy for the reversal of heart failure". N Engl J Med. 355 (18): 1873–84. doi:10.1056/NEJMoa053063. PMID 17079761.
  5. ↑ Slaughter MS, Rogers JG, Milano CA, Russell SD, Conte JV, Feldman D; et al. (2009). "Advanced heart failure treated with continuous-flow left ventricular assist device". N Engl J Med. 361 (23): 2241–51. doi:10.1056/NEJMoa0909938. PMID 19920051.
  6. ↑ 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)
  7. ↑ Gissi-HF Investigators. Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG; et al. (2008). "Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial". Lancet. 372 (9645): 1223–30. doi:10.1016/S0140-6736(08)61239-8. PMID 18757090. Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-11
  8. ↑ Template:DorlandsDict
  9. ↑ Fonarow GC, Abraham WT, Albert NM; et al. (2008). "Factors Identified as Precipitating Hospital Admissions for Heart Failure and Clinical Outcomes: Findings From OPTIMIZE-HF". Arch. Intern. Med. 168 (8): 847–854. doi:10.1001/archinte.168.8.847. PMID 18443260. Unknown parameter |month= ignored (help)
  10. ↑ Nieminen MS, Böhm M, Cowie MR; et al. (2005). "Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the Task Force on Acute Heart Failure of the European Society of Cardiology". Eur. Heart J. 26 (4): 384–416. doi:10.1093/eurheartj/ehi044. PMID 15681577. Unknown parameter |month= ignored (help)
  11. ↑ He J; Ogden LG; Bazzano LA; Vupputuri S; et al. (2001). "Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study". Arch. Intern. Med. 161 (7): 996–1002. doi:10.1001/archinte.161.7.996. PMID 11295963.
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