acute heart failure (AHF)
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Introduction
A sudden cardiac event resulting in an acute decline in cardiac output, insufficient perfusion of tissues & acute pulmonary & systemic venous congestion.
Etiology
- myocardial ischemia or infarction
- cardiac arrhythmias
- ventricular septal defect
- uncontrolled, severe hypertension
- pulmonary embolism
- valvular failure
- acute dilated cardiomyopathy
- aortic dissection
- cardiac rupture
- cardiac tamponade
- high-output states
- NSAIDs may increase risk of acute on chronic heart failure[15]
Epidemiology
- 50% of hospitalizations for acute heart failure in patients with reduced LVEF[20]
Clinical manifestations
- pulmonary edema is the most common manifestation
- symptoms
- sudden, extreme dyspnea
- pink, frothy sputum
- diaphoresis
- signs
- symptoms
- hepatic congestion mimicking an intra-abdominal process
- less common
- associated with jugular venous distension & right heart failure
- older patients hospitalized with acute heart failure
- more likely to be female
- more likely to have diastolic heart failure
- more likely to have gradual onset of symptoms
- more likely to have atypical presentation
- heart failure may present as abdominal pain in children & adolescents due to reduced intestinal blood flow[26]
Laboratory
- complete blood count to rule out anemia
- serum urea nitrogen, serum creatinine
- BUN/creatinine to rule out renal failure
- arterial blood gas (ABG)
- urinalysis
- serum electrolytes
- serum potassium > 4.5 mEq/L may be associated with worse outcomes[22]
- low serum Mg+2, low serum Na+ portend poor prognosis[4]
- markers of myocardial infarction
- serum creatine kinase & serum CK-MB
- cardiac-specific troponin-I or troponin-C may predict higher mortality[5][17]
- arterial blood gas
- elevated serum BNP (ventricular pressure overload)
- measured upon hospital admission to determine prognosis in patients with acutely decompensated heart failure[17]
- NT-proBNP in serum best predictor of mortality[15]
Diagnostic procedures
- electrocardiogram
- arrhythmias
- conduction delays
- non-sepcific ST-T changes
- echocardiography
- mitral regurgitation
- ventricular septal defect
- focal wall motion abonormalities
- pericardial effusion
- radionuclide ventriculography
- cardiac catheterization
Radiology
- chest X-ray
- lung ultrasonography outperforms chest-X-ray[13]
Complications
- pleural effusion: thoracentesis of no benefit, potential risks[36]
- thoracentesis of no benefit
- mortality among Medicare beneficiaries
- 1-year mortality for hospitalization survivors:
- 41% overall & 72% for high-risk admissions
- in hospital mortality 2.8% (2011-2016)[21]
- 1-year mortality for hospitalization survivors:
Differential diagnosis
- asthma
- COPD
- pneumonia
- pneumothorax
- pulmonary edema
- re-expansion
- high altitude
- neurogenic
- acute coronary syndrome
- dyspnea, but not chest pain associated with exacerbation of heart failure
- serum BNP may be elevated with acute coronary syndrome
- adult respiratory distress syndrome
- pulmonary embolism
- eclampsia
- heroin overdose
Management
- admit to hospital (CCU) most cases
- EHMRG scale may be used for assessment of hospitalization vs discharge from ED (see EHMRG scale for calculator)
- Barthel Index, serum creatinine & LV hypertrophy on EKG used in calculating score for predicting prognosis[19]
- treat volume overload [2]
- fluid & sodium restriction leads to increased thirst but not better outcomes[8]
- special case of right heart failure
- push normal saline even if central venous pressure elevated[2]
- avoid pressors until volume expansion produces pulmonary edema[2]
- oxygen
- ventilatory support for cardiogenic pulmonary edema[11][12]
- intravenous loop diuretic
- furosemide (Lasix) has poor & variable oral availability
- bumetanide (Bumex)
- no clear advantage of infusion vs bolus[6]
- initial IV dose should be at least the outpatient daily oral dose[2]
- increase diuretic dose to remove excess fluid[2][6]
- high-dose vs low-dose
- no outcome advantage
- tradeoff of renal toxicity vs symptom relief[6]
- earlier diuretic administration in the emergency department associated with lower mortality[18]
- diuretic resistance is > 240 mg furosemide equivalent daily[24]
- loop diuretic + metolazone 5 mg PO BID (metolazone not available IV)
- loop diuretic + tolvaptan 30 mg PO QD
- in hospitalized patients with acute heart failure, addition of tolvaptan to intravenous loop diuretic did not improve dyspnea despite greater weight loss & fluid loss[31]
- optimizing ACE inhibitor less important than removing excess fluid with diuretic[2]
- nitrates reduce preload & dilate coronary arteries
- sulingual nitroglycerin
- nitroglycerin or nitroprusside drip
- nitroprusside also reduces afterload
- useful when patients remain in heart failure after adequate diuresis[2]
- nitropaste
- hold for hypotension
- early nitrates plus hydralazine of no benefit over usual care[23]
- morphine reduces preload - hold for hypotension
- acetazolamide added to intravenous loop diuretic is associated with a higher rate of successful decongestion in patients with stage 3 chronic renal failure[32]
- worsening renal function occurs more frequently with acetazolamide, but this is not associated with adverse clinical outcomes[32]
- antiarrhythmic agents to control ventricular response to atrial fibrillation
- digoxin also improves cardiac contractility
- avoid increases in digoxin with acute renal failure
- diltiazem IV
- rapidly effective
- negative inotropic effect
- digoxin also improves cardiac contractility
- pressors for left heart failure (LV systolic dysfunction)
- norepinephrine (pressor of choice)
- heart failure with severe hypotension
- normal to low systemic vascular resistance
- vasoconstrictive, inotropic & chronotropic effects
- start 1-4 ug/min
- dopamine
- may be inferior to norepinephrine
- 5-10 ug/kg/min (inotropic & chronotropic)
- 10-20 ug/kg/min (vasoconstrictive)
- renal dose dopamine 2 ug/kg/min does not improve renal function in patients with acute heart failure[9]
- dobutamine
- may be inferior to norepinephrine
- better than milrinone in patients with renal insufficiency[2]
- preferable to adding metolazone for loop diuretic resistance
- refractory heart failure with poor cardiac output
- systolic blood pressure < 100 mm Hg
- inotropic effects
- decreased systemic vascular resistance
- start 2-5 ug/kg/min
- may be inferior to norepinephrine
- phosphodiesterase inhibitors
- amrinone
- milrinone
- load 50 ug/kg
- 0.375-0.75 ug/kg/min
- effects similar to dobutamine
- norepinephrine (pressor of choice)
- discontinue & avoid offending medications
- discontinue cilostazol (contraindicated with heart failure)
- avoid beta-blockers & calcium channel blockers (both negative inotropes)
- avoid esmolol drip even with tachycardia[2]
- risk of negative intropic effect greater than benefit of slowing heart rate (even with short 1/2 life of esmolol)[2]
- avoid esmolol drip even with tachycardia[2]
- SGLT-2 inhibitor therapy throughout hospitalization regardless of LVEF[34]
- SGLT-2 inhibitors have little effect on blood pressure
- empagliflozin
- increases urine output 25% over 5 days without adverse renal effects[30]
- improves health-related quality of life at 90 days after acute heart failure; benefits begin at day 15[29]
- aldosterone antagonists have little effect on blood pressure
- initiate at any time during hospitalization & continue at discharge unless contraindicated[34]
- natriuretic hormone
- nesiritide 0.005 ug/kg/min does not improve renal function in patients with acute heart failure[9]
- intra-aortic balloon pump & left ventricular assist device
- cardiogenic shock resistant to inotropic agents
- stabilization prior to revascularization
- coronary angiography with revascularization
- dialysis for heart failure complicated by anuria
- right heart catheterization does not improve outcomes in hospitalized patients with heart failure[2]
- delay elective surgery until stabilization[25]
- intravenous iron with ferric carboxymaltose may benefit stabilized hospitalized patients with iron-deficiency[27]
- follow-up
- close observation after stabilization
- observe for recurrent heart failure, dehydration, electrolyte abnormalities, drug toxicity
- telephone contact within 48 hours of discharge
- follow-up physician visit within 1 week after hospital discharge[2]
- early follow-up nurse home visit[2]
- intensive 3-month physical rehabilitation program focusing on strength, balance, mobility, & endurance started during hospitalization or shortly after discharge improves physical function[28]
- early & rapid uptitration of neurohormonal blockade[33]
- prognosis
- high mortality especially in the elderly
- 33% mortality within the 1st 3 months
- NT-proBNP in serum best short-term predictor of mortality[15]
- heart transplantation: median survival 11 years with normal quality of life[2]
More general terms
More specific terms
- acute diastolic heart failure
- acute right ventricular failure; cor pumonale
- cardiorenal syndrome
- high-output heart failure
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 241-42
- ↑ Jump up to: 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018, 2022
Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025 - ↑ Diagnosis and treatment of acute heart failure European Society of Cardiology (ESC) http://www.escardio.org/knowledge/guidelines
- ↑ Jump up to: 4.0 4.1 Gheorghiade M et al, Characterization and prognostic value of persistent hyponatremia in patients with severe heart failure in the ESCAPE trial. Arch Intern Med 2007, 167:1998 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17923601
- ↑ Jump up to: 5.0 5.1 Peacock WF 4th, De Marco T, Fonarow GC et al, Cardiac troponin and outcome in acute heart failure. N Engl J Med 2008 May 15; 358:2117 PMID: https://www.ncbi.nlm.nih.gov/pubmed/18480204 Free full text
- ↑ Jump up to: 6.0 6.1 6.2 6.3 Felker GM et al for the NHLBI Heart Failure Clinical Research Network. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med 2011 Mar 3; 364:797. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21366472
Fonarow GC. Comparative effectiveness of diuretic regimens. N Engl J Med 2011 Mar 3; 364:877. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21366480 - ↑ Lee DS et al. Prediction of heart failure mortality in emergent care: A cohort study. Ann Intern Med 2012 Jun 5; 156:767. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22665814
- ↑ Jump up to: 8.0 8.1 Aliti GB et al. Aggressive fluid and sodium restriction in acute decompensated heart failure: A randomized clinical trial. JAMA Intern Med 2013 May 20; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23689381 <Internet> http://archinte.jamanetwork.com/article.aspx?articleid=1689981
Cheitlin MD. Counterintuitive evidence concerning salt and water restriction in acute decompensated heart failure patients. JAMA Intern Med 2013 May 20 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23689640 <Internet> http://archinte.jamanetwork.com/article.aspx?articleid=1690004 - ↑ Jump up to: 9.0 9.1 9.2 Chen HH et al. Low-dose dopamine or low-dose nesiritide in acute heart failure with renal dysfunction: The ROSE Acute Heart Failure randomized trial. JAMA 2013 Dec 18; 310:2533 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24247300
- ↑ Silvers SM, Howell JM, Kosowsky JM, Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with acute heart failure syndromes. Ann Emerg Med. 2007 May;49(5):627-69. Epub 2007 Apr 3. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17408803
- ↑ Jump up to: 11.0 11.1 Yoshida M, Kadokami T, Momii H et al Enhancement of cardiac performance by bilevel positive airway pressure ventilation in heart failure. J Card Fail. 2012 Dec;18(12):912-8 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23207079
- ↑ Jump up to: 12.0 12.1 Weng CL, Zhao YT, Liu QH, et al. Meta-analysis: Noninvasive ventilation in acute cardiogenic pulmonary edema. Ann Intern Med. 2010;152(9):590-600 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20439577
- ↑ Jump up to: 13.0 13.1 Pivetta E et al. Lung ultrasound-implemented diagnosis of acute decompensated heart failure in the ED: A SIMEU multicenter study. Chest 2015 Jul 1; 148:202 PMID: https://www.ncbi.nlm.nih.gov/pubmed/25654562
- ↑ Fermann GJ, Collins SP. Initial management of patients with acute heart failure. Heart Fail Clin. 2013 Jul;9(3):291-301 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23809416
- ↑ Jump up to: 15.0 15.1 15.2 15.3 Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019 - ↑ Lazzarini V, Mentz RJ, Fiuzat M, Metra M, O'Connor CM. Heart failure in elderly patients: distinctive features and unresolved issues. Eur J Heart Fail. 2013 Jul;15(7):717-23. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23429975 Free PMC Article
- ↑ Jump up to: 17.0 17.1 17.2 Yancy CW et al 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017. copublished in J Am Coll of Cardiol http://circ.ahajournals.org/content/circulationaha/early/2017/04/26/CIR.0000000000000509.full.pdf
- ↑ Jump up to: 18.0 18.1 Matsue Y, Damman K, Voors AA et al. Time-to-furosemide treatment and mortality in patients hospitalized with acute heart failure. J Am Coll Cardiol 2017 Jun 27; 69:3042. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28641794 <Internet> http://www.sciencedirect.com/science/article/pii/S0735109717371863
Januzzi JL Jr, Felker GM. Door-to-furosemide therapy in the ED: New quality metric or just a piece of the puzzle? J Am Coll Cardiol 2017 Jun 27; 69:3052 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28641795 <Internet> http://www.sciencedirect.com/science/article/pii/S0735109717373229 - ↑ Jump up to: 19.0 19.1 Miro O, Rossello X, Gil V et al. Predicting 30-day mortality for patients with acute heart failure in the emergency department: A cohort study. Ann Intern Med 2017 Oct 3; PMID: https://www.ncbi.nlm.nih.gov/pubmed/28973663
Rahko PS. Acute heart failure in the emergency department: What is the prognosis? Ann Intern Med 2017 Oct 3; PMID: https://www.ncbi.nlm.nih.gov/pubmed/28973163 - ↑ Jump up to: 20.0 20.1 Chang PP, Wruck LM, Shahar EP et al. Trends in hospitalizations and survival of acute decompensated heart failure in four US communities (2005-2014): ARIC Study Community Surveillance. Circulation. 2018 Jul 3;138(1):12-24. Epub 2018 Mar 8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29519849 https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.117.027551
- ↑ Jump up to: 21.0 21.1 Parikh KS, Sheng S, Hammill BG et al. Characteristics of acute heart failure hospitalizations based on presenting severity. Circ Heart Fail 2019 Jan 11; 12:e005171 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30630340 https://www.ahajournals.org/doi/10.1161/CIRCHEARTFAILURE.118.005171
- ↑ Jump up to: 22.0 22.1 Sullivan KF, Kashef MA Knee AB et al. Examining the "repletion index": The association between serum potassium and outcomes in hospitalized patients with heart failure. J Hosp Med 2019 Jul 24; PMID: https://www.ncbi.nlm.nih.gov/pubmed/31339844 https://www.journalofhospitalmedicine.com/jhospmed/article/204919/hospital-medicine/examining-repletion-reflex-association-between-serum
- ↑ Jump up to: 23.0 23.1 Kozhuharov N, Goudev A, Flores D et al. Effect of a strategy of comprehensive vasodilation vs usual care on mortality and heart failure rehospitalization among patients with acute heart failure: The GALACTIC randomized clinical trial. JAMA 2019 Dec 17; 322:2292 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31846016
- ↑ Jump up to: 24.0 24.1 Cox ZL, Hung R, Lenihan DJ, Testani JM. Diuretic strategies for loop diuretic resistance in acute heart failure: The 3T trial. JACC Heart Fail 2019 Dec 11; PMID: https://www.ncbi.nlm.nih.gov/pubmed/31838029
- ↑ Jump up to: 25.0 25.1 NEJM Knowledge+ Question of the Week. July 14, 2020 https://knowledgeplus.nejm.org/question-of-week/195/
- ↑ Jump up to: 26.0 26.1 NEJM Knowledge+ Question of the Week. August 25, 2020 https://knowledgeplus.nejm.org/question-of-week/5081/
Madriago E, Silberbach M. Heart failure in infants and children. Pediatr Rev 2010 Jan; 31:4 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20048034 Free article - ↑ Jump up to: 27.0 27.1 Ponikowski P et al. on behalf of the AFFIRM-AHF Investigators. Ferric carboxymaltose for iron deficiency at discharge after acute heart failure: A multicentre, double-blind, randomised, controlled trial. Lancet 2020 Nov 13; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33197395 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32339-4/fulltext
- ↑ Jump up to: 28.0 28.1 Kitzman DW, Whellan DJ, Duncan P et al. Physical rehabilitation for older patients hospitalized for heart failure. N Engl J Med 2021 May 16; PMID: https://www.ncbi.nlm.nih.gov/pubmed/33999544 https://www.nejm.org/doi/10.1056/NEJMoa2026141
- ↑ Jump up to: 29.0 29.1 Kosiborod MN et al. Effects of empagliflozin on symptoms, physical limitations and quality of life in patients hospitalized for acute heart failure - Results from the EMPULSE trial. Circulation 2022 Apr 4; [e-pub] PMID: https://www.ncbi.nlm.nih.gov/pubmed/35377706 https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.059725
- ↑ Jump up to: 30.0 30.1 30.2 Schulze PC et al. Effects of early empagliflozin initiation on diuresis and kidney function in patients with acute decompensated heart failure (EMPAG-HF). Circulation 2022 Jun 29; PMID: https://www.ncbi.nlm.nih.gov/pubmed/35766022 Free article https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.059038
- ↑ Jump up to: 31.0 31.1 NEJM Knowledge+ Complex Medical Care
Felker GM, Mentz RJ, Cole RT et al Efficacy and Safety of Tolvaptan in Patients Hospitalized With Acute Heart Failure. J Am Coll Cardiol. 2017 Mar 21;69(11):1399-1406. Epub 2016 Sep 18. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27654854 Free article. Clinical Trial. - ↑ Jump up to: 32.0 32.1 32.2 Meekers E, Dauw J, Martens P, et al. Renal Function and Decongestion With Acetazolamide in Acute Decompensated Heart Failure: The ADVOR Trial. Eur Heart J. 2023 Aug 25:ehad557. PMID: https://www.ncbi.nlm.nih.gov/pubmed/37623428
Verbrugge FH, Martens P, Dauw J Natriuretic Response to Acetazolamide in Patients With Acute Heart Failure and Volume Overload. J Am Coll Cardiol. 2023 May 23;81(20):2013-2024. PMID: https://www.ncbi.nlm.nih.gov/pubmed/37197845 - ↑ Jump up to: 33.0 33.1 33.2 Biegus J, Mebazaa A, Davison B et al Effects of Rapid Uptitration of Neurohormonal Blockade on Effective, Sustainable Decongestion and Outcomes in STRONG-HF. J Am Coll Cardiol. 2024 Jul 23;84(4):323-336. PMID: https://www.ncbi.nlm.nih.gov/pubmed/39019527 Clinical Trial. https://www.sciencedirect.com/science/article/abs/pii/S073510972407400X?via%3Dihub
- ↑ Jump up to: 34.0 34.1 34.2 Writing Committee; Hollenberg SM, Stevenson LW, Ahmad T et al 2024 ACC Expert Consensus Decision Pathway on Clinical Assessment, Management, and Trajectory of Patients Hospitalized With Heart Failure Focused Update: A Report of the American College of Cardiology Solution Set Oversight Committee J Am Coll Cardiol. 2024 Aug 2:S0735-1097(24)07449-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/39127954 https://www.jacc.org/doi/10.1016/j.jacc.2024.06.002
- ↑ Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2022;79:e263-e421. PMID: https://www.ncbi.nlm.nih.gov/pubmed/35379503
- ↑ Jump up to: 36.0 36.1 Glargaard S et al. A randomized controlled trial of thoracentesis in acute heart failure. Circulation 2025 Apr 22; 151:1150. PMID: https://www.ncbi.nlm.nih.gov/pubmed/40166829 PMCID: PMC12011436 https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.124.073521