Heart failure resident survival guide

For acute heart failure prevention click here.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahmoud Sakr, M.D. [2]; Ayokunle Olubaniyi, M.B,B.S [3]

Acute Heart Failure Resident Survival Guide Microchapters
Overview
Classification
Causes
FIRE
Diagnosis
Treatment Stage C Stage D Diuretic Therapy Medications
Do's
Don'ts

Overview

Acute heart failure can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure (also known as acute decompensated heart failure, flash pulmonary edema, ADHF). ADHF presents with acute shortness of breath due to the development of pulmonary edema (the rapid accumulation of fluid in the lung). Other signs and symptoms of ADHF include hypotension with impaired and organ perfusion manifested by worsening renal function, altered mentation and cold clammy extremities. ADHF is associated with a poor prognosis if not treated aggressively. Like chronic heart failure therapy, the goal is to improve symptoms but unlike chronic therapy the other goals are to improve oxygenation and hemodynamic stability. The mainstays of the acute medical treatment in acute decompensated congestive heart failure include oxygen to improve hypoxia, diuresis to reduce both preload and intravascular volume and vasodilators to reduce afterload. Some of the mainstays of chronic heart failure therapy are not initiated acutely (ACE inhibitors, beta blockers and digoxin).

Classification

Based on the Severity of Congestive Heart Failure

The New York Heart Association (NYHA) assessment of heart failure severity is often used to guide treatment:

NYHA classification	Description
I	No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure (HF)
II	Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF
III	Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF
IV	Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest

NYHA - New York Heart Association

Based on the Stage of Heart Failure

ACCF/AHA Stages	Description
A	At high risk for heart failure (HF) but without structural heart disease or symptoms of HF
B	Structural heart disease but without signs or symptoms of HF
C	Structural heart disease with prior or current symptoms of HF
D	Refractory HF requiring specialized interventions

ACCF - American College of Cardiology Foundation; AHA - American Heart Association

Based on Left Ventricular Ejection Fraction (LVEF)

• Heart failure with preserved ejection fraction (HFpEF) or diastolic heart failure: ejection fraction ≥ 50%
• Heart failure with reduced ejection fraction (HFrEF) or systolic heart failure: ejection fraction ≤ 40%

Causes

Life Threatening Causes

Acute decompensated heart failure is life threatening and should be treated as such irrespective of the underlying cause.

Common Causes

• Acute coronary syndrome
• Acute kidney injury
• Acute severe myocarditis
• Cardiac arrhythmias
• Cardiomyopathy
• Cardiotoxic agents - alcohol, cocaine
• Decompensation of an underlying chronic heart failure
• Hypertensive crisis
• Pulmonary embolus
• Systemic Inflammatory response syndrome
• Valvular heart disease

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Boxes in red signify that an urgent management is needed.

Abbreviations: MAP: Mean arterial pressure; NYHA: New York Heart Association; SBP: Systolic blood pressure

Identify cardinal findings that increase the pretest probability of acute heart failure ❑ Past medical history of heart failure ❑ History of orthopnea and paroxysmal nocturnal dyspnea ❑ Dyspnea ❑ Chest pain ❑ Pulmonary crepitations/rales/crackles ❑ Cool extremities ❑ Peripheral edema ❑ Third heart sound (S3)

Does the patient have any of the following findings that require urgent management? ❑ Hypotension (SBP < 90 mmHg or drop in MAP >30 mmHg) ❑ Altered mental status ❑ Cold and clammy extremities ❑ Urine output <0.5mL/kg/hr ❑ Metabolic acidosis

Yes

No

Treat cardiogenic shock ❑ Admit to intensive care unit (ICU) or coronary care unit (CCU) for closer monitoring ❑ Initiate oxygen therapy for patients with oxygen saturation <90% or PaO2 <60 mmHg (8.0 kPa) ❑ Non-rebreather face masks ❑ Continuous positive airway pressure (CPAP) or noninvasive positive pressure ventilation (NPPV) if oxygen saturation cannot be maintained by the use face masks ❑ Mechanical ventilation (PEEP) usually when CPAP or NPPV fails ❑ For SBP 85 - 100 mm Hg ❑ Consider dobutamine at 2.5 to 5 mcg/kg/min or milrinone at 0.125 to 0.75 mcg/kg/min ❑ For SBP < 85 mm Hg ❑ Consider dopamine at 5 to 10 mcg/kg/min and norepinephrine at 0.2–1.0 mcg/kg/min ❑ Consider intra-aortic balloon pump, if hypotension persists ❑ Consider left ventricular assist devices in severe cases Click here for cardiogenic shock resident survival guide

Does the patient have severe symptoms of heart failure? ❑ NYHA class III ❑ Marked limitation of physical activity ❑ Comfortable at rest, but less than ordinary activity causes symptoms of HF ❑ NYHA class IV ❑ Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest

Yes

No

Urgent treatment ❑ Diuretic therapy (click for details) ❑ Administer oxygen (as noted above) ❑ Administer IV vasodilators e.g.,nitroglycerin at 5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated. Max of 400mcg/min OR nesiritide at 2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion. Max of 0.03 mcg/kg/minute

Continue with the complete diagnostic approach below

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.

Abbreviations: ARDS: Acute respiratory distress syndrome; BNP: B-type natriuretic peptide; BUN: Blood urea nitrogen; CAD: Coronary artery disease; CBC: Complete blood count; CCB: Calcium channel blocker; CT: Computed tomography; CXR: Chest X-ray; DM: Diabetes mellitus; EKG: Electrocardiogram; GDMT: Guideline-directed medical therapy; HTN: Hypertension; LVEF: Left ventricular ejection fraction; LVH: Left ventricular hypertrophy; MI: Myocardial infarction; MRI: Magnetic resonance imaging; NT-pro BNP: N-terminal pro-brain natriuretic peptide; OCPs: Oral contraceptive pills; PAWP: Pulmonary artery wedge pressure; TSH: Thyroid stimulating hormone

Characterize the symptoms: Symptoms of fluid accumulation ❑ Dyspnea ❑ At rest ❑ Exertional ❑ Paroxysmal nocturnal dyspnea ❑ Orthopnea ❑ Cough ❑ Peripheral edema ❑ Ascites Symptoms of reduced cardiac output ❑ Fatigue ❑ Oliguria ❑ Dizziness ❑ Syncope ❑ Altered mental status ❑ Cyanosis ❑ Abdominal pain (suggestive of mesenteric ischemia) Symptoms suggestive of precipitating events ❑ Chest pain (if myocardial ischemia is present) ❑ Palpitations (suggestive of arrhythmias) ❑ Fever (suggestive of sepsis) Nonspecific symptoms ❑ Anorexia ❑ Bloating ❑ Nausea ❑ Weight loss Obtain a detailed history: ❑ Past medical history ❑ Atrial fibrillation ❑ Cardiomyopathy ❑ Diabetes mellitus ❑ Hypertension ❑ Myocarditis ❑ Previous myocardial infarction ❑ Prior heart failure ❑ Sleep apnea ❑ Thyroid disease ❑ Valvular heart disease ❑ Medication history ❑ Noncompliance with previously prescribed medications for heart failure ❑ Intake of the following drugs: ❑ Alcohol ❑ Beta blockers ❑ Calcium channel blockers like verapamil which can exacerbate CHF or diltiazem which can cause peripheral edema ❑ Chemotherapy drugs - anthracyclines ❑ NSAIDs which should not be given in CHF ❑ Thiazolidinedione ❑ Family history ❑ History of dilated cardiomyopathy ❑ Radiation to the chest

Examine the patient: General appearance: ❑ Ill-looking ❑ In respiratory distress ❑ Usually in upright sitting position Vitals: ❑ Temperature ❑ Fever (suggestive of underlying infection) ❑ Pulse ❑ Tachycardia ❑ Narrow pulse pressure (<25 mmHg) ❑ Blood pressure ❑ Hypotension (suggestive of circulatory collapse) ❑ Hypertension ❑ Respiration ❑ Tachypnea (commonest symptom) ❑ Pulse oximetry assure sat is > 90% Weight: ❑ Subtract 'dry weight' from current weight to quantitate extent of volume overload and edema Skin ❑ Cool and clammy, in hypoperfusion or cardiogenic shock ❑ Cyanosis, in severe hypoxemia ❑ Anasarca Neck examination: ❑ Jugular vein distention is often present Respiratory examination ❑ Tachypnea ❑ Wheeze (suggestive of cardiac asthma) ❑ Dullness at lung bases, suggestive of pleural effusion ❑ Crackles/crepitations/rales Cardiovascular examination ❑ Displaced apex beat (suggestive of enlarged left ventricle) ❑ Parasternal heave (suggestive of elevated right ventricular pressure) ❑ S3 (typical) or S4 or both ❑ New or changed murmur (suggestive of an underlying valvular heart diseases) ❑ Mitral regurgitation - Holosystolic murmur ❑ Aortic regurgitation - Decrescendo diastolic murmur ❑ Aortic stenosis - Crescendo-decrescendo systolic ejection murmur with ejection click Abdominal examination The following suggest volume overload and / or poor forward cardiac output: ❑ Hepatojugular reflux ❑ Hepatomegaly ❑ Ascites Extremity examination ❑ Pedal edema Neurological examination ❑ Altered mental status ❑ Syncope (suggestive of aortic stenosis or pulmonary embolism)

Order tests: Routine (Class I, level of evidence C) ❑ CBC (rule out anemia) ❑ Troponin ❑ Elevated in myocardial ischemia and acute cardiogenic pulmonary edema, particularly if creatinine clearance (CrCl) is reduced ❑ Troponin T ≥0.1 ng/mL (associated with poor survival) ❑ Electrolytes ❑ Dilutional hyponatremia (with the presence of edema) ❑ Serum calcium ❑ Serum magnesium which can be lowered by diuresis ❑ Serum bicarbonate to monitor contraction alkalosis with diuresis ❑ BUN, creatinine may be elevated due to poor renal perfusion ❑ Urinalysis ❑ Fasting blood sugar ❑ Fasting lipid profile ❑ Liver function tests ❑ TSH ❑ BNP or NT-pro BNP (if diagnosis is uncertain) Heart failure is unlikely if: ❑ BNP ≤ 100 pg/mL, or ❑ NT-pro BNP ≤ 300 pg/mL ❑ Chest X-ray (Class I, level of evidence C) ❑ Cardiomegaly (cardiothoracic ratio >50%) ❑ Cardiogenic pulmonary edema ❑ Kerley B lines ❑ Peribronchial cuffing ❑ Cephalization Chest X-ray findings in a patient with acute heart failure ❑ EKG ❑ Low QRS voltage due to electrically inert myocardium ❑ Arrhythmia (usually atrial fibrillation which carries a poor prognosis and requires slowing to improve filling & cardiac output) ❑ Poor R wave progression (suggestive of a prior MI) ❑ Left ventricular hypertrophy (consistent with a history of hypertension) ❑ Left bundle branch block (LBBB) due to prior MI, may result in dysynchrony ❑ Left atrial enlargement due to valvular disease or hypertension ❑ Non-specific ST segment and T wave changes may suggest ischemia ❑ 2-D echocardiography with Doppler (Class I, level of evidence C) ❑ Assess ventricular size, function, wall thickness, wall motion, and valve function ❑ Radionuclide ventriculography or MRI ❑ To assess LVEF and volume when echocardiography is inadequate ❑ To assess myocardial infiltrative processes or scar burden (MRI) ❑ Coronary angiography (in settings of ischemia) ❑ Pulmonary artery catheterization in respiratory distress or shock or to definitively assess volume status and tailor therapy Order additional tests to rule out other etiologies: ❑ ANA, rheumatoid factor (for rheumatologic diseases) ❑ Diagnostic tests for hemochromatosis, pheochromocytoma ❑ Endomyocardial biopsy (when myocarditis is suspected)

Consider alternative diagnoses: Alternative diagnoses Features Acute asthma ❑ Wheeze ❑ Reversal of symptoms following administration of bronchodilators ARDS ❑ Severe hypoxia ❑ Bilateral opacities on chest X-ray ❑ PCWP < 15 mmHg Pneumonia ❑ Fever, cough, sputum ❑ Consolidation on chest X-ray Pulmonary embolism ❑ Pleuritic chest pain, cough, S4 ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on CT pulmonary angiography

Assess the stage of heart failure using the ACCF/AHA staging system to guide chronic therapy

Stage C ❑ Patients with structural heart disease This refers to patients with the following: ❑ Previous MI ❑ LV remodeling* (including LVH + low EF) ❑ Asymptomatic valvular disease AND ❑ Signs or symptoms of heart failure LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury

Stage D ❑ Refractory heart failure ❑ Marked symptoms at rest ❑ Recurrent hospitalizations

Treatment

The treatment of acute heart failure is largely dependent on whether the patient has a preserved ejection fraction (diastolic heart failure) or reduced ejection fraction (systolic heart failure)

Initial stabilization: ❑ Assess the airway ❑ Position the patient upright at an angle of 45 degrees ❑ Check pulse oximetry ❑ If hypoxemia is present (Sa02 < 90% or Pa02 <60 mmHg) ❑ Give oxygen by: ❑ Non-rebreather face masks ❑ Continuous positive airway pressure ❑ Avoid IV morphine - may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms though ❑ Ensure continuous cardiac monitoring ❑ Secure intravenous access with 18 gauge canula ❑ Monitor vitals signs ❑ Monitor fluid intake and urine output

Consider admission if the following is present: ❑ Hypotension and/or cardiogenic shock ❑ Poor end-organ perfusion - worsening renal function, cold clammy extremities, altered mental status ❑ Hypoxemia - Sa02 ↓90% ❑ Atrial fibrillation with a rapid ventricular response resulting in hypotension ❑ Presence of an acute coronary syndrome

Treat precipitating causes/co-morbidities Click for detailed management ❑ Atrial fibrillation Atrial fibrillation and acute decompensated heart failure are intimately related; the successful management of atrial fibrillation is often critical to the success of reversing the acute decompensation. Points to note: ❑ Rate control of atrial fibrillation is the mainstay of arrhythmia therapy. ❑ IV diltiazem (has no negative inotropic effect) at a loading dose of 0.25 mg/kg over 2 min and maintenance dose of 5 to 15 mg/h ❑ IV short acting esmolol at a loading dose of 500 mcg/kg over 1 min and maintenance dose at 60 to 200 mcg/kg/min Avoid the use of drugs with negative inotropic effects such as beta blockers and non-dihydropyridine calcium channel blockers e.g., verapamil in the treatment of acute decompensated systolic heart failure ❑ Consider cardioversion ❑ If the patient is in cardiogenic shock ❑ If new onset atrial fibrillation is the clear precipitant of the hemodynamic decompensation Note: Unfractionated heparin should be administered before cardioversion ❑ Acute aortic/mitral regurgitation ❑ Acute coronary syndrome ❑ Anemia ❑ Aortic dissection ❑ Hypertensive crisis ❑ Renal failure ❑ Sepsis

Assess hemodynamic and volume status ❑ Congestion at rest (dry vs. wet) "Wet" suggested by orthopnea, ↑JVP, rales, S3, pedal edema ❑ Low perfusion at rest (warm vs. cold) "Cold" suggested by narrow pulse pressure, cool extremities, hypotension

Classify the patient based on the left ventricular ejection fraction

Diastolic heart failure LVEF ≥ 50%

Systolic heart failure LVEF ≤ 40%

Treatment ❑ Rate control - to prolong left ventricular filling time ❑ Administer beta blockers, especially in the setting of atrial fibrillation ❑ Diuretic therapy to reduce volume overload (click for details) Avoid excess diuresis in patients with diastolic heart failure as they are prone to hypotension due to reductions in preload ❑ Relief of ischemia ❑ Coronary revascularization in the setting of angina and demonstrable myocardial ischemia ❑ The use of inotropes such as dobutamine, milrinone is not indicated

Treatment Consider the following: ❑ Diuretic therapy (click for details) ❑ IV vasodilators ❑ Inotropic therapy ❑ Vasopressor support ❑ ACE inhibitors ACE inhibitor should not be initiated within the first 12 to 24 hours of acute decompensation of heart failure as these agents may result in prolonged hypotension and impaired end organ perfusion It can be continued in: ❑ Hemodynamically stable patients with acute decompensated heart failure without a rising creatinine or hyperkalemia ❑ Beta blockers Beta blockers should not be initiated during acute decompensated heart failure It can be continued in: ❑ A patient chronically on beta blockers in the absence of hypotension ❑ Aldosterone antagonists It can be continued in: ❑ A patients chronically on aldosterone antagonists prior to the development of acute decompensated heart failure in the absence of hypotension, hyperkalemia, and impaired renal function

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 ventricular 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)

Indications for cardiac transplantation ❑ Refractory cardiogenic shock ❑ Documented dependence on intravenous inotropic support to maintain adequate organ perfusion ❑ Peak VO2 less than 10 mL/kg per min with achievement of anaerobic metabolism

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 prior to discharge ❑ ACE inhibitors ❑ Beta blockers ❑ Aldosterone antagonists ❑ Omega-3 fatty acid ❑ 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

Diuretic Therapy Details

Evidence of volume overload

❑ Low sodium diet (<2 g daily) ❑ Free water restriction to <2 L/day if the Na is < 130 meq/L, and < 1 L/day or more if the Na is < 125 meq/L ❑ Initiate IV diuretics due to poor absorption from gut ❑ Frusemide 40 mg, or ❑ Torsemide 20 mg, or ❑ Bumetanide 1 mg Contraindications to IV Diuresis ❑ Hypotension and cardiogenic shock Note - Give a higher dose of IV diuretic in patients chronically on diuretic therapy (e.g., 2.5x their maintenance dose)

Symptomatic improvement?

Yes

No

Maintain current IV diuretic dose

Double IV diuretic dose and titrate according to patient's response or when the maximum dose is reached

No symptomatic improvement

Add ❑ Another diuretic e.g., IV chlorothiazide or oral metolazone or ❑ An aldosterone antagonist e.g., spironolactone or eplerenone, in post MI patients Indications: ❑ 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% K+- sparing diuretic e.g amiloride or triamterene should not be administered with aldosterone antagonist given the risk of hyperkalemia

Adjuvants to diuretics ❑ Low dose dopamine to preserve renal function and renal blood flow ❑ IV nitroprusside, nitroglycerin, or nesiritide for hemodynamically stable patients to relieve dyspnea ❑ Vasopressin antagonists (e.g. tolvaptan; start with 15mg orally daily)

No symptomatic improvement (refractory edema)

Ultrafiltration or dialysis

General measures ❑ Monitor BP, volume status, congestion ❑ Daily weights ❑ Intake and output charts ❑ Convert all IV diuretic to oral ❑ Daily serum electrolytes, urea & creatinine ❑ DVT prophylaxis

Medications

Drug Class	Drug	Daily dose	Maximum daily dose
Loop diuretics	Furosemide	20 to 40 mg once or twice In HF patients on loop diuretic, the initial IV dose should be greater or equal to their chronic oral daily dose.	600 mg
	Bumetanide	0.5 to 1.0 mg once or twice	10 mg
	Torsemide	10 to 20 mg once	200 mg
Thiazide diuretics	Chlorothiazide	250 to 500 mg once or twice	1000 mg
	Hydrochlorothiazide	25 mg once or twice	200 mg
	Metolazone	2.5 mg once	20 mg
K+- sparing diuretic	Amiloride	5 mg once	20 mg
	Spironolactone	12.5 to 25.0 mg once	50 mg
	Triamterene	50 to 75 mg twice	200 mg
ACE inhibitors	Enalapril	2.5 mg twice	10 to 20 mg twice
	Lisinopril	2.5 to 5 mg once	20 to 40 mg once
	Ramipril	1.25 to 2.5 mg once	10 mg once
ARBs	Candesartan	4 to 8 mg once	32 mg once
	Losartan	25 to 50 mg once, 50 to 150 mg once
	Valsartan	20 to 40 mg twice	160 mg twice
Beta blockers	Bisoprolol	1.25 mg once	10 mg once
	Carvedilol	3.125 mg twice	50 mg twice
	Metoprolol succinate	12.5 to 25.0 mg once	200 mg once
Aldosterone antagonists	Spironolactone	12.5 to 25.0 mg once	25 mg once or twice
	Eplerenone	25 mg once	50 mg once
Inotropes	Dopamine	5 to 10 mcg/kg/min
	Dobutamine	2.5 to 5 mcg/kg/min
	Milrinone	0.125 to 0.75 mcg/kg/min
Vasodilators	Nitroglycerin	5 to 10 mcg/min, increase dose by 5-10mcg/min every 3-5 mins as tolerated	Max is 400mcg/min
	Nitroprusside	5 to 10 mcg/min, increase dose by 5-10mcg/min every 5 mins as tolerated	Max is 400mcg/min
	Nesiritide	2 mcg/kg bolus; then 0.01 mcg/kg/minute continuous infusion	Max of 0.03 mcg/kg/minute
Hydralazine and isosorbide dinitrate	Fixed-dose combination	37.5 mg hydralazine/20 mg isosorbide dinitrate 3 times daily, 75 mg hydralazine/40 mg isosorbide dinitrate 3 times daily
	Individual doses	Hydralazine: 25 to 50 mg 3 or 4 times daily, 300 mg daily in divided doses Isosorbide dinitrate: 20 to 30 mg 3 or 4 times daily	120 mg daily in divided doses
Digoxin		0.125 to 0.25 mg daily. There is no need for a loading dose in CHF. Drugs that increase the concentration of digoxin include amiodarone, quinidine and verapamil

Do's

• Guideline-directed medical therapy (GDMT) is a term which represents the optimal medical therapy in the management of heart failure as defined by ACCF/AHA. These are primarily the class 1 recommendations. It involves the use of ACE inhibitors or (ARBs), beta blockers, aldosterone antagonists, and hydralazine/nitrate medications.
• Order an echocardiogram as soon as possible in the absence of a recent one or if the patient's clinical status is deteriorating.
• Digoxin decreases hospitalization but not mortality in the RALES study. It can be used in CHF & afib to reduce the ventricular response. In the RALES study, a level of < 1 ng/ml was associated with efficacy. Levels > 1 ng/ml not associated with greater efficacy & associated with higher mortality. No need to load a CHF patient with dig. For majority of patients with normal Cr, a daily dose of 0.25 mg of digoxin is usually adequate. In the older patient or in those patients with renal impairment, a dose of 0.125 mg per day may be adequate. Drugs that increase the concentration of digoxin include amiodarone, quinidine and verapamil.
• DVT prophylaxis unless contraindicated.
• Consider adding another diuretic (e.g. metolazone or thiazides) for worsening congestion despite high doses of loop diuretics.
• Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications.
• Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .

Don'ts

• Avoid, if possible, NSAIDs, sympathomimetics, tricyclic antidepressants, class I and III antiarrhythmics (except amiodarone), and nondihydropyridine calcium channel blockers (diltiazem, verapamil as they can be harmful in acute decompensated HF.
• Don't administer parenteral inotropes in normotensive patients with acute decompensated HF without evidence of decreased organ perfusion.
• Don't combine an ACEI, ARB, and aldosterone antagonist in patients with HFrEF unless otherwise indicated as this combination carries a risk of renal dysfunction and hyperkalemia.
• Don't use aldosterone receptor antagonists in patients with hyperkalemia or renal insufficiency when serum creatinine is more than 2.5 mg/dL in men or more than 2.0 mg/dL in women (or estimated glomerular filtration rate <30 mL/min/1.73 m2), and/or potassium more than 5.0 mEq/L.
• Don't use statins routinely without other indications.

References

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