Congestive heart failure AHA recommendations for hospitalized patient

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Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF
Diuretics
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Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Ultrafiltration
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ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahmoud Sakr, M.D. [2] Edzel Lorraine Co, D.M.D., M.D. [3]

2022 AHA/ACC/HFSA Heart Failure Guideline/ 2013 ACC/AHA Guideline, 2009 ACC/AHA Focused Update and 2005 Guidelines for the Diagnosis and Management of Heart Failure in the Adult (DO NOT EDIT) [1][2][3]

PATIENTS HOSPITALIZED WITH ACUTE DECOMPENSATED HF 2022 AHA/ACC/HFSA Heart Failure Guideline/ 2013 ACC/AHA Guideline, 2009 ACC/AHA Focused Update and 2005 Guidelines for the Diagnosis and Management of Heart Failure in the Adult (DO NOT EDIT) [1][2][3]

Assessment of Patients Hospitalized With Decompensated HF (DO NOT EDIT) [1][2][3]

Class I
"1. In patients hospitalized with HF, severity of congestion and adequacy of perfusion should be assessed to guide triage and initial therapy. [4] [5][6][7][8] (Level of Evidence: B-NR) "
"2. In patients hospitalized with HF, the common precipitating factors and the overall patient trajectory should be assessed to guide appropriate therapy. [8][9] (Level of Evidence: B-NR) "
"3. For patients admitted with HF, treatment should address reversible factors, establish optimal volume status, and advance GDMT toward targets for outpatient therapy.[9] (Level of Evidence: B-NR) "

Maintenance or Optimization of GDMT During Hospitalization (DO NOT EDIT) [1][2][3]

Class I
"1. In patients with HFrEF requiring hospitalization, preexisting GDMT should be continued and optimized to improve outcomes, unless contraindicated. [10][11][12][13][14] (Level of Evidence: B-NR) "
"2. In patients experiencing mild decrease of renal function or asymptomatic reduction of blood pressure during HF hospitalization, diuresis and other GDMT should not routinely be discontinued. [15][16][17][18][19][20](Level of Evidence: B-NR) "
"3.In patients with HFrEF, GDMT should be initiated during hospitalization after clinical stability is achieved.[11][12][14][21][22][23][24][25][26][27] (Level of Evidence: B-NR) "
"4.In patients with HFrEF, if discontinuation of GDMT is necessary during hospitalization, it should be reinitiated and further optimized as soon as possible. [28][29][30][31] (Level of Evidence: B-NR) "

Diuretics in Hospitalized Patients: Decongestion Strategy (DO NOT EDIT) [1][2][3]

Class I
"1. Patients with HF admitted with evidence of significant fluid overload should be promptly treated with intravenous loop diuretics to improve symptoms and reduce morbidity. Felker GM, Lee KL, Bull DA, et al. Diuretic strategies in patients with acute

decompensated heart failure. N Engl J Med. 2011;364:797–805. (Level of Evidence: B-NR) "

"2. For patients hospitalized with HF, therapy with diuretics and other guideline-directed medications should be titrated with a goal to resolve clinical evidence of congestion to reduce symptoms and rehospitalizations. [31][32][33][34][7][5](Level of Evidence: B-NR) "
"3.For patients requiring diuretic treatment during hospitalization for HF, the discharge regimen should include a plan for adjustment of diuretics to decrease rehospitalizations.[35] (Level of Evidence: B-NR) "
"4.In patients with HF when diuresis is inadequate to relieve symptoms and signs of congestion, it is reasonable to intensify the diuretic regimen using either: a. higher doses of intravenous loop diuretics [36][33]); or b. addition of a second diuretic. [33] (Level of Evidence: B-NR) "

Parenteral Vasodilation Therapy in Patients Hospitalized With HF (DO NOT EDIT) [1][2][3]

Class IIb
"1. In patients who are admitted with decompensated HF, in the absence of systemic hypotension, intravenous nitroglycerin or nitroprusside may be considered as an adjuvant to diuretic therapy for relief of dyspnea. [37][38] (Level of Evidence: B-NR) "

VTE Prophylaxis in Hospitalized Patients (DO NOT EDIT) [1][2][3]

Class I
"1. In patients hospitalized with HF, prophylaxis for VTE is recommended to prevent venous thromboembolic disease. [39][40][41] (Level of Evidence: B-R) "

Evaluation and Management of Cardiogenic Shock (DO NOT EDIT) [1][2][3]

Class I
"1. In patients with cardiogenic shock, intravenous inotropic support should be used to maintain systemic perfusion and preserve end-organ performance.[42][43][44][45][46]23977106[47][48] (Level of Evidence: B-NR) "
Class IIa
"2. In patients with cardiogenic shock, temporary MCS is reasonable when end-organ function cannot be maintained by pharmacologic means to support cardiac function. [49][50][51][52][53][54][55][56][57] (Level of Evidence: B-NR) "
"3. In patients with cardiogenic shock, management by a multidisciplinary team experienced in shock is reasonable. [57][58][59][60][61][62] (Level of Evidence: B-NR) "
Class IIb
"4. In patients presenting with cardiogenic shock, placement of a PA line may be considered to define hemodynamic subsets and appropriate management strategies.[63][64][65][66][67] (Level of Evidence: B-NR) "
"5. For patients who are not rapidly responding to initial shock measures, triage to centers that can provide temporary MCS may be considered to optimize management. [57][58][59][60][61][62] (Level of Evidence: C-LD) "

Integration of Care: Transitions and Team-Based Approaches (DO NOT EDIT) [1][2][3]

Class I
"1. In patients with high-risk HF, particularly those with recurrent hospitalizations for HFrEF, referral to multidisciplinary HF disease management programs is recommended to reduce the risk of hospitalization. [68][69][70][71] (Level of Evidence: B-R) "
"2. In patients hospitalized with worsening HF, patient-centered discharge instructions with a clear plan for transitional care should be provided before hospital discharge. [72](Level of Evidence: B-NR) "
Class IIa
"3. In patients hospitalized with worsening HF, participation in systems that allow benchmarking to performance measures is reasonable to increase use of evidence-based therapy, and to improve quality of care. [73][74][75][76](Level of Evidence: B-NR) "
"4. In patients being discharged after hospitalization for worsening HF, an early follow up, generally within 7 days of hospital discharge is reasonable to optimize care and reduce rehospitalization. [77][78](Level of Evidence: B-NR) "

External Links

References

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