| Class I
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| "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) "
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"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)."
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| "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) "
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| "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) "
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| "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) "
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| "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) "
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| "12. Medications should be reconciled in every patient and adjusted as appropriate on admission to and discharge from the hospital. (Level of Evidence: C) "
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| "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) "
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| "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. [2][3] (Level of Evidence: B) "
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| "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.[2][3] (Level of Evidence: B) "
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| "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) "
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| "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) "
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"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."
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| "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) "
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| "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) "
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