Acute Heart Failure CCS 2012 Guideline

Initial workup

Hx, PE, ECG, CXR, B/W (lytes, Cr, CBC, +/- Trop/BNP)

  1. Unlikely to be AHF – consider other Dx
  2. Uncertain – Test BNP
    • BNP <100 – consider other Dx
    • BNP100-500 – consider use of AHF score, eg PRIDE
    • BNP >500 – likely AHF – Tx
  3. Likely AHF – Tx

Consider Admission if

  1. NYHA3/4 with min improvement
  2. New dx of CHF
  3. Uncertain f/u
  4. O2<91%, SBP<90-100mmHg, HR>90bpm, RR>20
  5. ECG – ischemia, ventricular or atrial arrhythmia not under control
  6. Worsening renal function or comorbid conditions req Adm – syncope or pneumonia

Tx Goals

  1. Find etiology & precipitating factors
  2. Alleviate presenting symptoms
  3. Optimize meds
  4. Pt education & transition of care plan

  1. First 24 hr
    • IV/PO diuretic
    • +/- IV vasodilator, inotrope
    • continue in the absence of c/i: ACEI/ARB, MRA, BB
  2. During Hospitalization
    • IV/PO diuretic + ACEI/ARB
    • +/- IV vasodilator, inotrope, MRA
    • Continue in the absence of c/i: ARB, BB, Statin, Antiplatelet agents
  3. At discharge
    • IV/PO diuretic, ACEI/ARB, BB
    • +/- MRA, Statin, Antiplatelet, CRT, ICD
  4. Long-term f/u
    • IV/PO diuretic, ARB/ACEI, BB
    • +/- hydralazine/nitrate, statin, antiplatelet, revascularization

Diuretic Dosing

  1. eGFR>=60
    • New CHF – Furosemide 20-40mg IV 2-3 times daily
    • Established CHF – Furosemide bolus IV equivalent to po dose
  2. eGFR <60
    • New CHF – Furosemide 20-80mg IV 2-3 times daily
    • Established CHF – Furosemide bolus IV equivalent to oral dose
  3. Maintenance dose: lowest dose that allows for clinical stability

Suboptimal Response to diuretics

  1. Additional diuresis by on vol status – higher bolus more effective than freq lower doses
  2. Restrict salt and water
  3. Add another type of diuretic: thiazide (Metolazone 2.5-5mg ob/bid or HCZ 25-50mg) 30min before lasix, or spironolactone
  4. Positive inotropic agents if poor perfusion coexists with diuretic resistance
  5. HD if diuresis impeded by renal insufficiency

Assess progress

  1. Symptoms: Dyspnea,orthopnea, PND, overall well-being, fatigue
  2. Clinical findings: BP, RR, HR, O2 Sat, JVP, S3, rales, lower extremity edema
  3. Lab: Wt & net fluid balance, BUN, Cr, K+, Na+ BNP, Hgb

Criteria for discharge

  1. Presenting symptoms resolved
  2. VS stable (BP & HR) + Wt returned to “dry wt” & stable >24hr
  3. Inter-current cardiac and non-cardiac illness adequately dx and tx
  4. Chronic oral HF Tx initiated, titrated, optimized
  5. Pt education, d/c plan (labs, appt), primary care provider communication

  • O2 Sat >=92%
    • Consider O2 to inc FiO2, CPAP/BiPAP, Mechanical intubation
  • Vol Overload
    • IV Lasix 20-80mg bolus or infusion 5-20mg/hr
  • SBP<90 / MAP <60mmHg
    • Dopamine or vasopressor or Dobutamine
  • SBP 90-100 / MAP 60-65 mmHg
    • If low cardiac output – dobutamine or milrinone
  • SBP >100 / MAP >65 mmHg
    • add nitroglycerin IV/SL, nesiritide IV, nitroprusside IV
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Posted in 99 Priority Topics, Cardiac

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