Heart failure resident survival guide
For acute heart failure prevention click here.

# Overview
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

## 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.

## 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
- Borderline HFpEF: EF between 41 to 49%
- Improved HFpEF: EF >40% following a HFrEF

### Cardiac Output
- 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

# 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

# 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.
Abbreviations:
BU: Blood urea nitrogen;
COPD: Chronic obstructive pulmonary disease;
D5W: 5% dextrose solution in water ;
HF: Heart failure;
IV: Intravenous;
MAP: Mean arterial pressure;
Na: Sodium;
NSAID: Non steroidal anti-inflammatory drug;
SBP: Systolic blood pressure;
S3: Third heart sound;

# 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:
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;
ECG: Electrocardiogram;
JVP: Jugular venous pressure;
HF: Heart failure;
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;
SBP: Systolic blood pressure;
S1: First heart sound;
S3: Third heart sound;
TSH: Thyroid stimulating hormone

# 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

# 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

### Medications

# Do's

## 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.
- 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:
ACE inhibitor: may be continued if the patient is hemodynamically stable without a rising creatinine or hyperkalemia
Beta blocker: may be continued in the absence of hypotension
Aldosterone antagonist: may be continued in the absence of hypotension, hyperkalemia, and impaired renal function
- ACE inhibitor: may be continued if the patient is hemodynamically stable without a rising creatinine or hyperkalemia
- Beta blocker: may be continued in the absence of hypotension
- Aldosterone antagonist: may be continued in the absence of hypotension, hyperkalemia, and impaired renal function
- 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 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.

# 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.
- Don't administer K+- sparing diuretic e.g amiloride or triamterene with aldosterone antagonist due to the elevated risk of hyperkalemia.