This is the current release of the guideline.

This guideline updates a previous version: Heart Failure Society of America. Heart Failure Society of America (HFSA) practice guidelines. HFSA guidelines for management of patients with heart failure caused by left ventricular systolic dysfunction--pharmacological approaches. J Card Fail 1999 Dec;5(4):357-82.

Acute decompensated heart failure

Evaluation
Management
Treatment

Cardiology
Emergency Medicine
Internal Medicine

Advanced Practice Nurses
Pharmacists
Physician Assistants
Physicians

To provide recommendations for the evaluation and management of patients with acute decompensated heart failure

Patients with acute decompensated heart failure

1. Evaluation of signs and symptoms
2. Determination of plasma B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) when necessary
3. Hospital admission, as indicated, and careful monitoring of weight, fluid intake and output, vital signs, signs, symptoms, electrolytes, and renal function
4. Loop diuretics
5. Careful observation for the development of renal dysfunction and other side effects
6. Sodium and fluid restriction, increased doses of loop diuretics, continuous infusion of a loop diuretic, addition of a second type of diuretic orally or intravenously, or ultrafiltration, if needed
7. Intravenous nitroglycerin, nitroprusside, or nesiritide
8. Intravenous inotropes
9. Invasive hemodynamic monitoring in specific patients
10. Evaluation of admitted patients for precipitating factors
11. Discharge planning

• Hospitalization rate
• Survival rate
• Sensitivity and specificity of diagnostic tests

Searches of Electronic Databases
Searches of Unpublished Data

Databases searched included Medline and Cochrane. In addition, the guideline developers polled experts in specific areas for data.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Level A: Randomized, Controlled, Clinical Trials
May be assigned based on results of a single trial

Level B: Cohort and Case-Control Studies
Post hoc, subgroup analysis, and meta-analysis
Prospective observational studies or registries

Level C: Expert Opinion
Observational studies – epidemiologic findings
Safety reporting from large-scale use in practice

Review of Published Meta-Analyses
Systematic Review

Not stated

Expert Consensus

The Heart Failure Society of America (HFSA) Guideline Committee sought resolution of difficult cases through consensus building. Written documents were essential to this process, because they provided the opportunity for feedback from all members of the group. On occasion, consensus of Committee opinion was sufficient to override positive or negative results of almost any form or prior evidence.

"Is recommended": Part of routine care
Exceptions to therapy should be minimized.

"Should be considered": Majority of patients should receive the intervention.
Some discretion in application to individual patients should be allowed.

"May be considered": Individualization of therapy is indicated

"Is not recommended": Therapeutic intervention should not be used

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

The process of moving from ideas of recommendations to a final document includes many stages of evaluation and approval. Every section, once written, had a lead reviewer and 2 additional reviewers. After a rewrite, each section was assigned to another review team, which led to a version reviewed by the Committee as a whole and then the Heart Failure Society of America (HFSA) Executive Council, representing 1 more level of expertise and experience. Out of this process emerged the final document.

None provided

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations").

The recommendations are supported by randomized controlled clinical trials, cohort and case-control studies, and expert opinion.

Accurate evaluation and appropriate management of patients with acute decompensated heart failure

• High-dose diuretic therapy is a marker for increased mortality during hospitalization for heart failure (HF), as it is in chronic HF. Whether this is a direct adverse effect of diuretics or a reflection of the severity of the HF is unclear. However, complications of diuretic therapy that could result in poor outcomes include electrolyte disturbance, hypotension, and volume depletion. Treatments that effectively relieve symptoms in patients with acute decompensated heart failure (ADHF), such as diuretics, vasodilators, and inodilators, can be associated with significant short- and even long-term adverse effects on renal function.
• Troponin release has been documented during hospitalization for ADHF. These findings suggest that myocyte loss from necrosis and apoptosis may be accelerated in patients admitted with acute decompensated heart failure. Mechanisms potentially accounting for cell death are still being determined but may include neurohormonal activation and pharmacologic therapy. Medications that increase myocardial oxygen demand have the potential to induce ischemia and may damage hibernating but viable myocardium, especially in patients with ischemic heart disease. Experimental data indicate that dobutamine can cause necrosis in hibernating myocardium. One outcome study comparing dobutamine to levosimendan suggested greater risk in patients randomized to dobutamine.
• Administration of intravenous furosemide has been associated with neurohormonal activation, which may result in worsening of hemodynamics secondary to vasoconstriction in the early stages of therapy.
• Despite beneficial effects in acute HF, diuretics may be associated with a variety of adverse effects that often require alterations in their use or the use of concomitant medications. Patients treated with diuretics should be monitored carefully for excessive urine output, development of hypotension, and reductions in serum potassium, magnesium, and renal function. Serial determinations of creatinine and blood urea nitrogen (BUN) are particularly important when these side effects are present or anticipated. Diuretic therapy must be highly individualized based on the degree of fluid overload present and the degree of volume loss produced to minimize these side effects. (See the original guideline document for further details about hypokalemia, hypotension, neurohormonal activation, and other side effects of diuretics.)
• The adverse effects of nitroglycerin therapy include headache and symptomatic hypotension. Hypotension is more likely when preload is low, which may occur as filling pressures decline in response to diuretic therapy.
• The potential side effects of nesiritide include hypotension, headache, and worsening renal function. The risk of hypotension appears to be dose dependent and was less frequent in the Vasodilator in the Management of Acute Heart Failure (VMAC) study than in earlier trials that used higher maintenance doses. The incidence of symptomatic hypotension in the VMAC trial was similar in patients treated with nitroglycerin versus nesiritide. Because of the longer effective half-life of nesiritide, hypotension may last longer with nesiritide than with nitroglycerin. The risk of hypotension appears to be reduced in the absence of volume depletion, so correct assessment of fluid status will help to minimize this side effect. If rapid onset of hemodynamic effect is not needed, the bolus dose of nesiritide can be omitted, which may lessen the risk of symptomatic hypotension, although this strategy has not been tested in controlled trials. Headache is not a common side effect and only infrequently is severe enough to warrant discontinuation of the drug.

It must be recognized that the evidence supporting recommendations is based largely on population responses that may not always apply to individuals within the population. Therefore, data may support overall benefit of 1 treatment over another but cannot exclude that some individuals within the population may respond better to the other treatment. Thus guidelines can best serve as evidence-based recommendations for management, not as mandates for management in every patient. Furthermore, it must be recognized that trial data on which recommendations are based have often been carried out with background therapy not comparable to therapy in current use. Therefore, physician decisions regarding the management of individual patients may not always precisely match the recommendations. A knowledgeable physician who integrates the guidelines with pharmacologic and physiologic insight and knowledge of the individual being treated should provide the best patient management.

An implementation strategy was not provided.

Living with Illness

Effectiveness

Not applicable: The guideline was not adapted from another source.

1999 (revised 2006 Feb)

Heart Failure Society of America, Inc - Disease Specific Society

Heart Failure Society of America, Inc

Comprehensive Heart Failure Practice Guideline Committee

Committee Members: Kirkwood F. Adams, Jr, MD (Co-Chair); JoAnn Lindenfeld, MD (Co-Chair); J. Malcolm O. Arnold, MD; David W. Baker, MD; Denise H. Barnard, MD; Kenneth Lee Baughman, MD; John P. Boehmer, MD; Prakash Deedwania, MD; Sandra B. Dunbar, RN, DSN; Uri Elkayam, MD; Mihai Gheorghiade, MD; Jonathan G. Howlett, MD; Marvin A. Konstam, MD; Marvin W. Kronenberg, MD; Barry M. Massie, MD; Mandeep R. Mehra, MD; Alan B. Miller, MD; Debra K. Moser, RN, DNSc; J. Herbert Patterson, PharmD; Richard J. Rodeheffer, MD; Jonathan Sackner-Bernstein, MD; Marc A. Silver, MD; Randall C. Starling, MD, MPH; Lynne Warner Stevenson, MD; Lynne E. Wagoner, MD

HFSA Executive Council: Gary S. Francis, MD, President; Michael R. Bristow, MD, PhD; Jay N. Cohn, MD; Wilson S. Colucci, MD; Barry H. Greenberg, MD; Thomas Force, MD; Harlan M. Krumholz, MD; Peter P. Liu, MD; Douglas L. Mann, MD; Ileana L. Piña, MD; Susan J. Pressler, RN, DNS; Hani N. Sabbah, PhD; Clyde W. Yancy, MD

Committee members and reviewers from the Executive Council received no direct financial support from the Heart Failure Society of America (HFSA) or any other source for the development of the guideline. Administrative support was provided by the Heart Failure Society of America staff, and the writing of the document was performed on a volunteer basis by the Committee. Financial relationships that might represent conflicts of interest were collected for all members of the Guideline Committee and of the Executive Council, who were asked to disclose potential conflicts and recuse themselves from discussions when necessary. Current relationships are shown in Table 1.5 of the "Development and Implementation" companion document (see the "Availability of Companion Documents" field).

This is the current release of the guideline.

This guideline updates a previous version: Heart Failure Society of America. Heart Failure Society of America (HFSA) practice guidelines. HFSA guidelines for management of patients with heart failure caused by left ventricular systolic dysfunction--pharmacological approaches. J Card Fail 1999 Dec;5(4):357-82.

None available

This NGC summary was completed by ECRI on July 31, 2006. The information was verified by the guideline developer on August 10, 2006. This summary was updated by ECRI Institute on July 12, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Troponin-1 Immunoassay.