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==Gas gangrene==
==CHF==
==CHF==
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Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
Click here for the detailed management of [[Hyperkalemia resident survival guide|hyperkalemia]] and [[Hypokalemia resident survival guide|hypokalemia]]</div>}}
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==Underlying Anatomic Abnormalities Causing Heart Failure==
{{familytree/start}}
{{familytree | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider admission:'''<ref name="pmid20610207">{{cite journal |author=Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Katz SD, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WH, Teerlink JR, Walsh MN |title=HFSA 2010 Comprehensive Heart Failure Practice Guideline |journal=[[Journal of Cardiac Failure]] |volume=16 |issue=6 |pages=e1–194 |year=2010 |month=June |pmid=20610207 |doi=10.1016/j.cardfail.2010.04.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1071-9164(10)00173-9 |accessdate=2013-04-29}}</ref><br>
----
❑ [[Hypotension]] and/or [[cardiogenic shock]]  <br>
❑ Poor end-organ perfusion - [[worsening renal function]], [[cold clammy extremities]], [[altered mental status]] <br>
❑ [[Hypoxemia]] - Sa02 ↓90%<br>
❑ [[Atrial fibrillation]] with a rapid ventricular response resulting in [[hypotension]]<br>
❑ Presence of an [[acute coronary syndrome]]</div>}}
{{familytree | | | | | |!| | |}}
{{familytree | | | | | C01 | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess hemodynamic and volume status'''<br>
❑ [[Congestion|Congestion at rest]]<br>e.g., [[orthopnea]], ↑[[JVP]], [[rales]], [[Heart sounds#Third heart sound S3|S3]], [[pedal edema]]<br>
❑ Low perfusion at rest <br>e.g., [[Pulse pressure|narrow pulse pressure]], [[cool extremities]], [[hypotension]]</div>}}
{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | Z01 | | | |Z01='''Classify the patient based on the<br> left ventricular ejection fraction'''}}
{{familytree | | | |,|-|^|-|.| |}}
{{familytree | | | D01 | | D02 | |D01='''Systolic heart failure<br>LVEF ≤ 40%'''|D02='''Diastolic heart failure<br>LVEF ≥ 50%'''}}
{{familytree/end}}
==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===
*The [[cardiac output]] is reduced, and the [[systemic vascular resistance]] ([[SVR]]) is high.  In low output failure, there is an inadequate supply of blood flow to meet normal metabolic demands.
===High Output Failure===
*The [[cardiac output]] is increased, and the [[systemic vascular resistance]] ([[SVR]]) is low.  Rather than an inadequate supply of blood flow to meet normal metabolic demands as occurs in low output failure, in high output failure there is an excess requirement for oxygen and nutrients and the demand outstrips what the heart can provide.<ref>{{DorlandsDict|nine/000953450|high-output heart failure}}</ref> Causes of high output heart failure include severe [[anemia]], Gram negative [[septicaemia]], [[beriberi]] (vitamin B<sub>1</sub>/thiamine deficiency), [[thyrotoxicosis]], [[Paget's disease of bone|Paget's disease]], [[arteriovenous fistula]]e, or [[arteriovenous malformation]]s.
==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), [[cardiac arrhythmia|arrhythmias]], uncontrolled [[hypertension]], or a patient's failure to maintain a fluid restriction, diet, or medication.<ref name="OPTIMIZE-HF">{{cite journal |author=Fonarow GC, Abraham WT, Albert NM, ''et al.'' |title=Factors Identified as Precipitating Hospital Admissions for Heart Failure and Clinical Outcomes: Findings From OPTIMIZE-HF |journal=Arch. Intern. Med. |volume=168 |issue=8 |pages=847–854 |year=2008 |month=April |pmid=18443260 |doi=10.1001/archinte.168.8.847}}</ref> 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 [[Non-steroidal anti-inflammatory drug|NSAIDs]] and [[thiazolidinedione]]s, may also precipitate decompensation.<ref>{{cite journal |author=Nieminen MS, Böhm M, Cowie MR, ''et al.'' |title=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 |journal=Eur. Heart J. |volume=26 |issue=4 |pages=384–416 |year=2005 |month=February |pmid=15681577 |doi=10.1093/eurheartj/ehi044 |url=http://eurheartj.oxfordjournals.org/cgi/content/full/26/4/384}}</ref>
==Differential Diagnosis of the Underlying Causes of Chronic Heart Failure==
===Common Causes of Left Sided Heart Failure===
* [[Aortic Regurgitation|Aortic regurgitation]]
* [[Aortic Stenosis|Aortic stenosis]]
* [[Hypertension]]
* [[Mitral Regurgitation|Mitral regurgitation]]
* [[Myocardial ischemia]]
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:<ref>{{cite journal |author=He J; Ogden LG; Bazzano LA; Vupputuri S, ''et al.'' |title=Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study|journal=Arch. Intern. Med. |volume=161 |issue=7 |pages=996–1002|year=2001 |pmid= 11295963 |doi=10.1001/archinte.161.7.996 }}</ref>
#[[Ischaemic heart disease]] 62%
#[[Tobacco smoking|Cigarette smoking]] 16%
#[[Hypertension]] (high blood pressure)10%
#[[Obesity]] 8%
#[[Diabetes]] 3%
#[[Valvular heart disease]] 2%  (much higher in older populations)
===Cardiomyopathies and Inflammatory Diseases===
=====[[Restrictive Cardiomyopathies]]=====
*[[Alcohol-Induced cardiomyopathy]]
*[[Amyloidosis]]
*[[Anthracycline induced cardiomyopathy]]
*[[Anthracyclines]]
*[[Arrhythmogenic right ventricular dysplasia]]
*[[Becker's muscular dystrophy]]
*[[Cardiac transplant]]
*[[Cocaine related cardiomyopathy]]
*[[Diabetic cardiomyopathy]]
*[[Endocardial fibrosis]]
*[[Eosinophilic heart disease]]
*[[Hemochromatosis]]
*Primary (idiopathic)
*[[Kearns-Sayre syndrome]]
*[[Radiation therapy]]
*[[Sarcoidosis]]
*Storage diseases
*[[Tumor]] infiltration
=====[[Dilated Cardiomyopathies]]=====
*[[Duchenne muscular dystrophy]]
*[[Chagas' disease]]
*[[Limb-girdle muscular dystrophy]]
*[[Mitochondrial myopathy]]
*[[Peripartum cardiomyopathy]]
*[[Trastuzumab]] [[Herceptin-lnduced Cardiomyopathy]]
=====Inflammatory Cardiomyopathies=====
*[[Bacterial Myocarditis]]
*[[Fungal myocarditis]]
*[[Giant Cell Myocarditis]]
*[[Myocarditis|Protozoal Myocarditis]]: [[Trypanosomiasis]] ([[Chagas Disease]])
*[[Rickettsial Myocarditis]]
*[[Sarcoidosis]]
*[[Spirochetal Infections]]
*[[Viral Myocarditis]]
===Congestive Heart Failure as a Consequence of Valvular Heart Disease===
*[[Acute aortic regurgitation]]
*[[Acute mitral regurgitation]]
*[[Aortic stenosis with Left Ventricular Systolic Dysfunction]]
*[[Chronic aortic regurgitation]]
*[[Chronic mitral regurgitation]]
*[[Mitral Stenosis]]
===Congestive Hert Failure Secondary to Congenital Heart Disease===
'''A. Causes of Congestive Heart Failure in Adults with Unoperated Congenital Heart Diseases'''
*[[Arrhythmia]]
*[[Atrial septal defect]] with [[mitral regurgitation]]] secondary to myxomatous mitral valve
*[[Congenital mitral regurgitation]]
*[[Drug abuse]], [[alcohol abuse]]
*[[Eisenmenger's syndrome]]
*[[Endocarditis]]
*Fibrocalcific degeneration of abnormal [[aortic valve]]
*[[Pregnancy]]
*Systemic ventricular dysfunction and/or [[tricuspid regurgitation]] in congenitally corrected transposition of the great arteries
*Other degenerative diseases ([[coronary artery disease]], [[hypertension]])
'''B. Causes of Congestive Heart Failure in Adults with Operated Congenital Heart Diseases'''
*[[Arrhythmia]]
*[[Endocarditis]]
*Myocardial dysfunction
*Persistent left-to-right shunt
*Prosthetic valve dysfunction
*Pulmonary vascular disease
*Status post [[Fontan operation]]
*Valvular regurgitation
*Other degenerative diseases ([[coronary artery disease]], [[hypertension]])
=== Right Ventricular Failure ===
Factors affected right ventricle and to be eliminated during management of congestive heart failure.
A. Right ventricular myocardial dysfunction
#[[Right ventricular myocardial infarction]]
#[[Dilated cardiomyopathy]]
#[[Arrhythmogenic right ventricular dysplasia|Right ventricular dysplasia]]
B. Primary right ventricular pressure overload
#[[Left ventricular failure]]
#[[Mitral valve]] disease
#[[Atrial myxoma]]
#[[Pulmonary veno-occlusive disease]]
#[[Cor pulmonale]]
#:*[[Chronic obstructive pulmonary disease]]
#:*[[Primary pulmonary hypertension]]
#:*[[Pulmonary embolism]]
#[[Pulmonic stenosis]]
#:*[[Supravalvular pulmonic stenosis]]
#:*[[Valvular pulmonic stenosis]]
#:*[[Subvalvular pulmonic stenosis]]
#[[Ventricular septal defect]]
#Aortopulmonary communication
C. Primary right ventricular volume overload
#[[Pulmonic regurgitation]]
#[[Tricuspid regurgitation]]
#[[Atrial septal defect]]
#[[Partial anomalous pulmonary venous return]]
D. Impediment to right ventricular inflow
#[[Tricuspid stenosis]]
#[[Cardiac tamponade]]
#[[pericarditis |Constrictive pericarditis]]
#[[cardiomyopathy|Restrictive cardiomyopathy]]
== Differential Diagnosis of Causes of Heart Failure Segregated by Left and Right Sided Heart Failure==
===Left Ventricular Failure===
====Most Common Causes:====
* [[Aortic Regurgitation|Aortic regurgitation]]
* [[Aortic Stenosis|Aortic stenosis]]
* [[Hypertension]]
* [[Mitral Regurgitation|Mitral regurgitation]]
* [[Myocardial ischemia]]
====Expanded List of Causes:====
* [[Atrial fibrillation]]
* [[Alcoholism]]
* [[Anemia]]
* [[Angina]]
* [[Aortic Regurgitation|Aortic regurgitation]]
* [[Aortic Stenosis]]
* [[Arteriovenous fistula]]
* [[Beriberi]]
* [[aneurysm|Cardiac aneurysm]]
* [[Cardiomyopathy]]
* [[pericarditis|Constrictive pericarditis]]
* [[Drugs]], [[toxin]]s
* [[Hypertension]]
* [[Hyperthyroidism]]
* [[Hypovolemia]]
* [[Hypoxia]]
* Mediastinal tumors
* [[Mitral Regurgitation]]
* [[Myocardial Infarction]]
* [[Paget's Disease]]
* [[Pancoast's Tumor]]
* [[Pericardial effusion]]
* [[Pericardial tamponade]]
* [[Perimyocarditis]]
* [[Protein deficiency]]
* [[Restrictive cardiomyopathy]]
* [[Papillary muscle rupture|Rupture of the papillary muscles]]
* [[Sepsis]]
* [[Superior Vena Cava]] thrombosis
===Right Ventricular Failure ===
====Most Common Causes:====
* [[Cardiomyopathy]]
* [[Cor pulmonale]]
* [[myocarditis|Diffuse myocarditis]]
* Left heart failure
====Other Causes:====
* After [[left ventricular failure]]
* After pulmonary resection
* [[Alveolitis|Allergic alveolitis]]
* [[asthma|Bronchial asthma]]
* [[bronchitis|Chronic bronchitis]]
* [[Alveolitis|Honeycomb lung]]
* [[Hyperglobulia]]
* [[Emphysema]]
* [[Mitral Stenosis]]
* [[Right ventricular myocardial infarction]]
* [[Pickwickian Syndrome]]
* Pleural fibrosis
* [[Pneumoconiosis]]
* [[Pulmonary fibrosis]]
* [[Pulmonic regurgitation]]
* [[Pulmonic stenosis]]
* [[Sarcoidosis]]
* [[pulmonary emboli|Severe relapsing pulmonary emboli]]
* [[Silicosis]]
* [[Tachycardia]]
* [[Tricuspid insufficiency]]
===Others===
* [[Ascorbic acid deficiency]]
* [[Cardiac amyloidosis]]
* [[Carnitine deficiency]]
* Cervical vein stasis of non-cardiac genesis
* [[Congenital heart disease]]
* [[Cyanosis]] of non-cardiac genesis
* [[Diabetes Mellitus]]
* [[Ddx:Dyspnea|Dyspnea]] of non-cardiac genesis
* [[Edema]] of non-cardiac genesis
* [[Hemochromatosis]]
* [[Pleural effusion]] of non-cardiac genesis
* [[Pulmonary edema]] of non-cardiac genesis
* [[Thiamine deficiency]]
* [[Thyroid disease]]

Revision as of 14:51, 19 May 2014

Gas gangrene

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
 
 
 
  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
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