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

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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

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Tx Goals

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

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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

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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

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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

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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

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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

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• 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