Congestive heart failure AHA recommendations for hospitalized patient

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

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. The diagnosis of heart failure is primarily based on signs and symptoms derived from a thorough history and physical examination. Clinicians should determine the following: a. Adequacy of systemic perfusion; b. Volume status; c. The contribution of precipitating factors and/or comorbidities; d. If the heart failure is new onset or an exacerbation of chronic disease; and e. Whether it is associated with preserved ejection fraction. " " Chest radiographs, electrocardiogram, and echocardiography are key tests in this assessment. (Level of Evidence: C) "

"2. Concentrations of B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) should be measured in patients being evaluated for dyspnea in which the contribution of heart failure is not known. Final diagnosis requires interpreting these results in the context of all available clinical data and ought not to be considered a stand alone test. (Level of Evidence: A) "

"3. Acute coronary syndrome precipitating heart failure hospitalization should be promptly identified by electrocardiogram and cardiac troponin testing, and treated, as appropriate to the overall condition and prognosis of the patient. (Level of Evidence: C) "

"4. It is recommended that the following common potential precipitating factors for acute HF be identified as recognition of these comorbidities is critical to guide therapy: (Level of Evidence: C) " a. Acute coronary syndromes/Coronary ischemia; b. Severe hypertension; c. Atrial and Ventricular arrhythmias; d. Infections; e. Pulmonary emboli; f. Renal failure; and g. Medical or dietary noncompliance.

"5. Oxygen therapy should be administered to relieve symptoms related to hypoxemia. (Level of Evidence: C) "

"6. Whether the diagnosis of heart failure is new or chronic, patients who present with rapid decompensation and hypoperfusion associated with decreasing urine output and other manifestations of shock are critically ill and rapid intervention should be used to improve systemic perfusion. (Level of Evidence: C) "

"7. Patients admitted with heart failure and with evidence of significant fluid overload should be treated with intravenous loop diuretics. Therapy should begin in the emergency department or outpatient clinic without delay, as early intervention may be associated with better outcomes for patients hospitalized with decompensated heart failure. (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. Urine output and signs and symptoms of congestion should be serially assessed, and diuretic dose should be titrated accordingly to relieve symptoms and to reduce extracellular fluid volume excess. (Level of Evidence: C) "

"8. Effect of heart failure treatment should be monitored with careful measurement of fluid intake and output; vital signs; body weight, determined at the same time each day; clinical signs (supine and standing) and symptoms of systemic perfusion and congestion. Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of heart failure medications. (Level of Evidence: C) "

"9. When diuresis is inadequate to relieve congestion, as evidenced by clinical evaluation, the diuretic regimen should be intensified using either: (Level of Evidence: C) " a. Higher doses of loop diuretics; b. Addition of a second diuretic (such as metolazone, spironolactone or intravenous chlorothiazide); or c. Continuous infusion of a loop diuretic.

"10. In patients with clinical evidence of hypotension associated with hypoperfusion and obvious evidence of elevated cardiac filling pressures (e.g., elevated jugular venous pressure; elevated pulmonary artery wedge pressure), intravenous inotropic or vasopressor drugs should be administered to maintain systemic perfusion and preserve end organ performance while more definitive therapy is considered. (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 reduced ejection fraction experiencing a symptomatic exacerbation of heart failure requiring hospitalization during chronic maintenance treatment with oral therapies known to improve outcomes, particularly ACE inhibitors or ARBs and beta blocker therapy, it is recommended that these therapies be continued in most patients in the absence of hemodynamic instability or contraindications. (Level of Evidence: C) "

"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. Particular caution should be used when initiating beta blockers in patients who have required inotropes during their hospital course. (Level of Evidence: B) "

"16. 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) "

"17. Comprehensive written discharge instructions for all patients with a hospitalization for heart failure and their caregivers is strongly recommended, with special emphasis on the following 6 aspects of care: " a. Diet, b. Discharge medications, with a special focus on adherence, persistence, and uptitration to recommended doses of ACE inhibitor/ARB and beta blocker medication, c. Activity level, d. Follow-up appointments, e. Daily weight monitoring, and f. What to do if heart failure symptoms worsen. (Level of Evidence: C)

"18. Postdischarge systems of care, if available, should be used to facilitate the transition to effective outpatient care for patients hospitalized with heart failure. (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. In patients with evidence of severely symptomatic fluid overload in the absence of systemic hypotension, vasodilators such as intravenous nitroglycerin, nitroprusside or nesiritide can be beneficial when added to diuretics and/or in those who do not respond to diuretics alone. (Level of Evidence: C) "

"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. Ultrafiltration is reasonable for patients with refractory congestion not responding to medical therapy. (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) "

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