Heart failure resident survival guide
For acute heart failure prevention click here.
|Acute Heart Failure Resident Survival Guide Microchapters|
Heart failure is a complex syndrome characterized by inadequate blood ejection or impaired ventricular filling, leading to the inability of the heart to pump blood to meet the metabolic demands of the body. Heart failure is a clinical syndrome for which the diagnosis relies mainly on symptoms and physical examination findings. The main symptoms and signs of heart failure are dyspnea, volume overload (leading to pulmonary edema and/or peripheral edema), fatigue, and exercise intolerance. Acute decompensated heart failure (ADHF) is a life-threatening condition that can occur in the setting of a new onset heart failure or worsening of an existing chronic heart failure. Symptoms of ADHF may include dyspnea secondary to pulmonary edema, peripheral edema, hypotension, and impaired end organ perfusion that can manifest by worsening renal function, altered mental status, and cold clammy extremities. The mainstays of treatment of ADHF are 1) oxygen therapy to improve hypoxia, 2) diuresis to reduce both preload and intravascular volume, and 3) vasodilators to reduce afterload. The goals of treatment for chronic heart failure are to relieve symptoms, decrease hospitalization rate, and decrease morbidity and mortality. Treatment of heart failure includes identification and management of precipitating factors, lifestyle changes, pharmacological therapy, and devices.
Classification by Severity of Congestive Heart Failure
Shown below is a table comparing American College of Cardiology Foundation/American Heart Association (ACCF/AHA) stages to New York Heart Association (NYHA) classification of severity of heart failure.
|ACCF/AHA Stages||New York Heart Association (NYHA) Classification|
|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||I||No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF|
|C||Structural heart disease with prior or current symptoms of HF||I||No limitation of physical activity. Ordinary physical activity does not cause symptoms of 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|
|D||Refractory HF requiring specialized interventions||IV||Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest|
Classification by Other Factors
Left Ventricular Ejection Fraction (LVEF)
- Heart failure with reduced ejection fraction (HFrEF) or systolic heart failure: ejection fraction (EF) ≤40%
- Heart failure with preserved ejection fraction (HFpEF) or diastolic heart failure: EF ≥50%
- Borderline HFpEF: EF between 41 to 49%
- Improved HFpEF: EF >40% following a HFrEF
- Low cardiac output
- High stroke volume with/without cardiac output
Left vs. Right Sided
- Left sided: Pulmonary edema
- Right sided: Peripheral edema, elevated jugular venous pressure, hepatomegaly
Backwards vs. Forward
- Backwards: Congestion, elevated filling pressure
- Forwards: Low systemic perfusion
Life Threatening Causes
Acute decompensated heart failure is life threatening and should be treated as such irrespective of the underlying cause.
- Acute coronary syndrome
- Acute kidney injury
- Acute severe myocarditis
- Cardiac arrhythmias
- 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 of severe acute decompensated heart failure in need of immediate intervention.
Boxes in red signify that an urgent management is needed.
BU: Blood urea nitrogen;
COPD: Chronic obstructive pulmonary disease;
D5W: 5% dextrose solution in water ;
HF: Heart failure;
MAP: Mean arterial pressure;
NSAID: Non steroidal anti-inflammatory drug;
SBP: Systolic blood pressure;
S3: Third heart sound;
Identify cardinal findings that increase the pretest probability of acute decompensated heart failure
Does the patient have any of the following findings that require hospitalization and urgent management?
❑ Severe decompendated HF:
Admit to to a level of care that allows for constant ECG monitoring given the risk of arrhythmia
Assess congestion and perfusion:
Identify precipitating factor and treat accordingly:
Treat congestion and optimize volume status:
❑ Low sodium diet (<2 g daily)
❑ Consider low dose dopamine infusion for improved diuresis and renal blood flow (IIb-B)
Treat low perfusion:
Invasive hemodynamic monitoring:
❑ DO NOT INITIATE ACE INHIBITORS during an acute decompensation
Monitor laboratory tests:
Management of hyponatremia:
❑ Optimization of chronic home medications
Complete Diagnostic Approach
ANA: Antinuclear antibody;
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;
CHF: Congestive heart failure;
CT: Computed tomography;
CXR: Chest X-ray;
DM: Diabetes mellitus;
JVP: Jugular venous pressure;
HF: Heart failure;
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;
SBP: Systolic blood pressure;
S1: First heart sound;
S3: Third heart sound;
TSH: Thyroid stimulating hormone
Characterize the symptoms:
Symptoms of left-sided fluid accumulation:
❑ Paroxysmal nocturnal dyspnea
Obtain a detailed history:
❑ Medication history
❑ Family history
Determine the NYHA classification based on symptoms:
Examine the patient:
❑ Pulse oximetry (maintain oxygen sat ≥ 94% unless COPD)
Determine status of congestion and perfusion based on physical exam:
Low perfusion at rest (warm vs. cold)
The patient is:
Routine (Class I, level of evidence C)
❑ ECG (to help identify the cause of heart failure)
❑ Coronary angiography looking for CAD
Order additional tests to rule out other etiologies:
Consider alternative diagnoses:
Assess the stage of heart failure using the ACCF/AHA staging system to guide chronic therapy
❑ Patients with structural heart disease
❑ Signs or symptoms of heart failure
❑ Refractory heart failure
Prevention of Heart Failure in Stage A and B
Shown below is an algorithm depicting the management of stage A and B heart failure.
Abbreviations: ACE I: Angiotensin converting enzyme inhibitor; ACS: Acute coronary syndrome; CVD: Cardiovascular disease; DM: Diabetes mellitus; EF: Ejection fraction; HF: Heart failure; HTN: Hypertension; ICD: Implantable cardioverter defibrillator; MI: Myocardial infarction; PAD: Peripheral artery disease
What is the stage of heart failure (HF)?
|Stage A |
At high risk for HF but without structural heart disease or symptoms of HF
|Stage B |
Structural heart disease but without signs or symptoms of HF
Consider additional measures in selected patients:
❑ Administer ACE-I if history of MI or ACS and reduced EF to prevent symptoms and reduce mortality (I-A), in all decreased EF to prevent symptoms (I-A)
Treatment of Heart Failure in Stage C and D
Shown below is an algorithm depicting the management of stage C and D heart failure.
Abbreviations: ACE I: Angiotensin converting enzyme inhibitor; ARB: Angiotensin II receptor blocker; ACS: Acute coronary syndrome; BID: Twice a day; BNP: Brain natriuretic peptide; CRT: Cardiac resynchronization therapy CVD: Cardiovascular disease; DM: Diabetes mellitus; EF: Ejection fraction; GDMT: Guideline determined medial therapy; GFR: Glomerular filtration rate; HF: Heart failure; HFrEF: Heart failure reduced ejectoon fraction; HFpEF: Heart failure preserved ejection fraction; HTN: Hypertension; ICD: Implantable cardioverter defibrillator; LVEF: Left ventricular ejection fraction; MCS: Mechanical circulatory support; NYHA: New York Heart Association; MI: Myocardial infarction; PAD: Peripheral artery disease; TID: Three times a day
What is the stage of heart failure (HF)?
|Stage C HFrEF|
Structural heart disease with prior or current symptoms of HF and reduced ejection fraction
|Stage C HFpEF |
Structural heart disease with prior or current symptoms of HF and preserved ejection fraction
|Stage D |
Refractory HF requiring specialized interventions
Add-on drugs in selected patients:
Mechanical circulatory support (MCS)
|Drug Class||Drug||Daily dose||Maximum daily dose|
(duration of action: 6 to 8 h)
|PO dose for chronic heart failure: 20 to 40 mg once or twice|
IV dose for acute heart failure:
Initial IV bolus administered slowly over 1 to 2 minutes, then continuous IV infusion rate of 10-40 mg/h|| 600 mg
(duration of action: 4 to 6 h)
|PO dose for chronic heart failure: 0.5 to 1.0 mg once or twice||10 mg|
(duration of action: 12 to 16 h)
|PO dose for chronic heart failure: 10 to 20 mg once||200 mg|
(duration of action: 6 to 12 h)
|PO: 250 to 500 mg once or twice||1000 mg|
(duration of action: 6 to 12 h)
|PO: 25 mg once or twice||200 mg|
(duration of action: 12 to 24 h)
|PO: 2.5 mg once||20 mg|
|K+- sparing diuretic||Amiloride
(duration of action: 24 h)
|PO: 5 mg once||20 mg|
(duration of action: 1 to 3 h)
|PO: 12.5 to 25.0 mg once||50 mg|
(duration of action: 7 to 9 h)
|PO: 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|
|Carvedilol CR||10 mg once||80 mg once|
|Metoprolol succinate extended release||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, OR
10 to 15 mcg/kg/min
|Dobutamine||2.5 to 5 mcg/kg/min, OR
5 to 20 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
Isosorbide dinitrate: 20 to 30 mg 3 or 4 times daily
|Hydralazine: 300 mg daily in divided doses |
Isosorbide dinitrate: 120 mg daily in divided doses
Loading dose: PO- 10 to 15 mcg/kg (half the total loading dose initially, then 1/4th the loading dose every 6 to 8 hours two times), OR
Acute Decompensated Heart Failure
- Differentiate systolic and diastolic heart failure among patients with ADHF in order to guide therapy:
- Inotropic agents that increase contractility are not indicated as important for the patient with acute decompensated systolic heart failure.
- While beta blocker initiation is relatively contraindicated in acute decompensated systolic heart failure, control of tachycardia is very useful in the patient with diastolic heart failure to prolong left ventricular filling time.
- While the initiation of ACE inhibitors may not be recommended in acute decompensated systolic heart failure, ACE inhibition may be of benefit in acute decompensated diastolic heart failure.
- Rely on the patient's volume status to guide the aggressiveness of diuresis in ADHF.
- Continue chronic medications during acute decompensation in the following conditions:
- 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 and 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.
- Convert all IV diuretic to oral forms in anticipation of discharge.
- Schedule an early follow-up visit (within 7 to 14 days) and early telephone follow-up (within 3 days) of hospital discharge .
Chronic Heart Failure
- 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.
- 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.
- Don't administer K+- sparing diuretic e.g amiloride or triamterene with aldosterone antagonist due to the elevated risk of hyperkalemia.
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