Heart failure - Congestive heart failure - CHF

Heart failure; Congestive heart failure - Acute

Definition  

A complex clinical syndrome resulting from any structural or functional cardiac abnormality that impairs the ability of the ventricle to fill with or eject blood

Because not all patients with heart failure have volume overload at the time of the initial or subsequent evaluation, the term heart failure is preferred over the older congestive heart failure term .

 

Suspected or known coronary artery disease and evaluation of functional impairment  

* Cardiovascular stress test using treadmill

 

Coronary arteriosclerosis  

* Coronary angiography

 

Suspected or known coronary artery disease  

* Radionuclide study of heart

* Stress echocardiography

 

Evaluation of nutritional status  

* Prealbumin measurement

* Nitrogen balance test

 

Medical History  

* Acute coronary syndrome

* Hypertension, acute

* Atrial arrhythmia

* Ventricular arrhythmia

* Infectious disease

* Pulmonary embolism [Pulmonary embolism - Acute]

* Renal failure

* Noncompliance with therapeutic regimen

* Drug or substance use factors

* Disorder of endocrine system

 

Findings  

* Dyspnea - Acute

* Fatigue

* Peripheral edema

* Respiratory crackles

* Decreased breath sounds

* Orthopnea

* Paroxysmal nocturnal dyspnea

* S3 gallop

* Jugular venous distention

* Hepatojugular reflux

* Hepatomegaly - Acute

* Ascites - Acute

* Nocturnal cough

* Nocturnal asthma

* Second heart sound split

* Tricuspid valve regurgitation

* Tachycardia

* Palpitations - Acute

* Chest pain - Acute

* Early satiety

* Nausea and vomiting - Acute

* Abdominal pain - Acute

* Cold extremities

* Confusion

* Syncope - Acute

 

Tests  

 

Suspected or known heart failure  

* Plain chest X-ray: Radiographic findings in heart failure may include evidence of cardiac chamber enlargement, increased pulmonary venous pressure, interstitial or alveolar edema, pleural effusions, valvular or pericardial calcification, or lung disease , but a chest x-ray should not be used as a primary test for identifying the specific cardiac dysfunction associated with HF .

 

Suspected or known heart failure  

* 12 lead ECG: In patients with heart failure, a 12-lead ECG is frequently abnormal and may show evidence of ischemia, myocardial infarction, left ventricular hypertrophy, cardiac conduction abnormality, or cardiac arrhythmia .

 

Suspected or known heart failure  

* Brain natriuretic peptide measurement: Acute heart failure is likely in the presence of acute dyspnea if the B-type natriuretic peptide (BNP) level is greater than 500 picog/mL or NT-proBNP is greater than 1000 picog/mL and is unlikely if BNP is less than 100 picog/mL or NT-proBNP is less than 300 picog/mL . Although levels vary, these cut-off values may still be useful to assess decompensation of chronic heart failure .

 

Suspected or known heart failure .  

* Two dimensional echocardiography: All patients presenting with heart failure should receive echocardiographic evaluation of left ventricular ejection fraction, left and right ventricular size and function, ventricular wall thickness, valve function, and pericardial pathology .

    

Suspected or known heart failure  

* Complete blood count

* Magnesium measurement, serum

* Serum calcium measurement

* Blood urea nitrogen measurement

* Fasting blood glucose measurement

* Liver function tests - general

* Thyroid stimulating hormone measurement

* Fasting lipid profile

 

Suspected or known heart failure  

* Urinalysis: Urinalysis should be obtained in all patients presenting with acute heart failure to detect infection and assess renal function, especially if hypotension may have occurred .

 

Suspected or known heart failure  

* Serum potassium measurement: The target level of serum potassium in heart failure patients ranges from 4.0 to 5.5 mmol/L; hypokalemia is independently associated with increased mortality .

 

Suspected or known heart failure  

* Sodium measurement, serum: In heart failure, serum sodium levels below 136 mEq/L are associated with increased risk of mortality and prolonged hospitalization .

 

Suspected or known heart failure  

* Creatinine measurement, serum: Serum creatinine should be measured and followed closely in all patients with heart failure. Creatinine levels provide management guidance as well as prognostic information .

 

Suspected or known heart failure  

* Albumin measurement, serum

 

Suspected or known acute coronary syndrome  

* Coronary angiography: Coronary angiography assesses risk and guides therapy in high-risk acute coronary syndrome patients, especially when invasive treatment is planned .

 

Differential Diagnosis  

* Acute myocardial infarction - Acute

* Pulmonary embolism - Acute

* Community acquired pneumonia - Acute

* Asthma - Acute

* Chronic obstructive pulmonary disease - Chronic

* Pulmonary hypertension - Chronic

* Obstructive sleep apnea - Chronic

* Renal failure

* Liver failure - Chronic

* Obesity - Chronic

* Physical deconditioning

* Anemia

* Hypoalbuminemia

* Deficiency of macronutrients

* Anxiety

* Depression - Chronic

 

Treatment  

 

Drug Therapy  

 

Diuretic therapy for systemic volume overload and in combination with nitrates for moderate to severe pulmonary edema  

 

FUROSEMIDE  

Adults: Initial dose 20 to 40 mg IV or orally daily or twice daily; up titrate as needed to obtain desired diuresis, then give determined dose daily or twice daily; maximum total daily dose 600 mg

Adults (continuous infusion): Loading dose 40 mg IV, then 10 to 40 mg per hour IV infusion

 

BUMETANIDE  

Adults: Initial dose 0.5 to 1 mg IV or orally daily or twice daily; up titrate as needed to obtain desired diuresis, then give determined dose daily or twice daily; maximum daily dose 10 mg

Adults (continuous infusion): Loading dose 1 mg IV, then 0.5 to 2 mg per hour IV infusion

 

TORSEMIDE  

Adults: Initial dose 10 to 20 mg IV or orally daily or twice daily; up titrate as needed to obtain desired diuresis, then give determined dose daily or twice daily; maximum daily dose 200 mg

Adults (continuous infusion): Loading dose 20 mg IV, then 5 to 20 mg per hour IV infusion

 

ETHACRYNIC ACID  

Adults: Initial dose 25 to 50 mg IV or orally daily or twice daily; up titrate as needed to obtain desired diuresis, then give determined dose daily or twice daily; maximum daily dose 200 mg

 

Persistent congestion with resistance to loop diuretic therapy  

 

CHLOROTHIAZIDE  

Adults: Initial dose 250 mg to 500 mg orally or 250 to 1000 mg IV once or twice daily

 

METOLAZONE  

Adults: Initial dose 2.5 mg orally once daily; maximum daily dose 20 mg

 

CHLORTHALIDONE  

Adults: Initial dose 12.5 to 25 mg orally daily; maximum daily dose 100 mg

 

HYDROCHLOROTHIAZIDE  

Adults: Initial dose 25 mg orally daily or twice daily; maximum total daily dose 200 mg

 

Vasodilator therapy for relief of pulmonary congestion in patients with systolic blood pressure greater than 100 mmHg  

 

NITROGLYCERIN

Adults: Initial dose 10 to 20 mcg/min, increased in increments of 5 mcg/kg every 3 to 5 minutes as needed; maintain mean blood pressure greater than 70 mmHg ; maximum dose 200 mcg/min

 

SODIUM NITROPRUSSIDE

Adults: Initial dose 0.1 to 0.2 mcg/kg/min, increasing every 5 minutes to achieve hemodynamic goals while avoiding hypotension (guideline recommendation) OR 0.3 mcg/kg/min IV infusion, titrate every few minutes to desired effect (product information); usual dose is 3 mcg/kg/min IV and maximum infusion rate is 10 mcg/kg/min

 

NESIRITIDE  

Adults: Initial dose 2 mcg/kg IV bolus, followed by 0.01 mcg/kg IV infusion ; may increase infusion by 0.005 mcg/kg, after a 1 mcg/kg IV bolus, every 3 hours if needed; maximum infusion rate 0.03 mcg/kg

 

Inotropic therapy for patients with advanced heart failure or persistent low cardiac output or persistent hypotension and tissue hypoperfusion, or selected patients with acute decompensation of heart failure with persistent and predominately systemic congestion, and in selected patients with acute coronary syndrome  

 

DOBUTAMINE HYDROCHLORIDE  

Adults: 2.5 to 15 mcg/kg/min

 

MILRINONE LACTATE  

Adults: Initial dose 50 mcg/kg IV bolus over 10 minutes, then 0.375 to 0.75 mcg/kg/min IV infusion OR 0.1 mcg/kg/min IV infusion, increase gradually to a final dose of 0.2 to 0.3 mcg/kg/min in most patients; maximal infusion rate 0.75 mcg/kg/min

 

Vasoconstrictor therapy for persistently low systolic blood pressure with organ hypoperfusion, life-threatening hypotension, or right ventricular dysfunction not responding to diuretics and inotropes .  

 

NOREPINEPHRINE BITARTRATE  

Adults: Initial dose 8 to 12 mcg/min IV infusion (large vein recommended); average maintenance rate 2 to 4 mcg/min

 

Procedural Therapy  

 

Respiratory distress  

* Airway management: Airway management must assume the first priority in the management of any seriously ill or injured patient .

 

Invasive pressure monitoring  

* Systemic arterial pressure monitoring

* Central venous pressure monitoring

 

Severe acute heart failure and impending or established respiratory or circulatory failure not responding to therapy  

* Pulmonary artery pressure monitoring

 

First-line mechanical assistance in medically unresponsive heart failure or as bridge therapy to cardiac transplant  

* Cardioassist by aortic balloon pump

 

Acute coronary syndrome  

* Percutaneous coronary intervention: Coronary revascularization with percutaneous coronary intervention is suitable for most high-risk patients with ST-segment elevation MI, non-ST-segment elevation MI, and unstable angina .

 

Coronary artery disease  

* Coronary artery bypass graft: CABG is the preferred revascularization strategy for most patients with significant left main coronary artery stenosis, 3-vessel coronary artery disease, and multivessel disease with treated diabetes or left ventricular dysfunction . It is appropriate in high-risk acute coronary syndrome when fibrinolysis or catheter-based treatment fails or is not indicated .