Evaluation and management of patients with acute decompensated heart failure: HFSA 2006 comprehensive heart failure prac

Brief Summary

GUIDELINE TITLE

Evaluation and management of patients with acute decompensated heart failure: HFSA 2006 comprehensive heart failure practice guideline.

BIBLIOGRAPHIC SOURCE(S)

Heart Failure Society of America. Evaluation and management of patients with acute decompensated heart failure. J Card Fail 2006 Feb;12(1):e86-103. [80 references] PubMed

GUIDELINE STATUS

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.

REGULATORY ALERT

FDA WARNING/REGULATORY ALERT

Note from the National Guideline Clearinghouse: This guideline references a drug(s)/intervention(s) for which important revised regulatory and/or warning information has been released.

June 8, 2007, Troponin-I Immunoassay: Class I Recall of all lots of the Architect Stat Troponin-I Immunoassay. The assay may report falsely elevated or falsely decreased results at and near a low level, which may impact patient treatment.
July 18, 2005, Natrecor (nesiritide): Due to recent questions raised about worsened renal function and mortality, recommendations were made on the appropriate use of the drug and on utilizing educational campaigns for clinicians.
May 19, 2005, Natrecor (nesiritide): Revisions to the ADVERSE REACTIONS/Effect on Mortality section of the prescribing information for patients with acutely decompensated congestive heart failure.

BRIEF SUMMARY CONTENT

** REGULATORY ALERT **
RECOMMENDATIONS
EVIDENCE SUPPORTING THE RECOMMENDATIONS
IDENTIFYING INFORMATION AND AVAILABILITY
DISCLAIMER

Go to the Complete Summary

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

The strength of evidence (A, B, C) and strength of recommendations are defined at the end of the "Major Recommendations" field.

The diagnosis of decompensated heart failure (HF) should be based primarily on signs and symptoms. (Strength of Evidence = C)
When the diagnosis is uncertain, determination of plasma B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentration should be considered in patients being evaluated for dyspnea who have signs and symptoms compatible with HF. (Strength of Evidence = A)

The natriuretic peptide concentration should not be interpreted in isolation, but in the context of all available clinical data bearing on the diagnosis of HF.
Hospital admission is recommended for patients presenting with acute decompensated heart failure (ADHF) when the clinical circumstances listed in Table 12.1(section a), below, are present. Patients presenting with ADHF should be considered for hospital admission when the clinical circumstances listed in Table 12.1(section b), below, are present. (Strength of Evidence = C)

Table 12.1: Recommendations for Hospitalizing Patients Presenting with ADHF

Recommendation	Clinical Circumstances
(a) Hospitalization Recommended	Evidence of severely decompensated HF, including: Hypotension Worsening renal function Altered mentation Dyspnea at rest Typically reflected by resting tachypnea Less commonly reflected by oxygen saturation <90% Hemodynamically significant arrhythmia Including new onset of rapid atrial fibrillation Acute coronary syndromes
(b) Hospitalization Should be Considered	Worsened congestion Even without dyspnea Typically reflected by a weight gain of >5 kg Signs and symptoms of pulmonary or systemic congestion Even in the absence of weight gain Major electrolyte disturbance Associated comorbid conditions Pneumonia Pulmonary embolus Diabetic ketoacidosis Symptoms suggestive of transient ischemic accident or stroke Repeated implantable cardioverter defibrillators (ICD) firings Previously undiagnosed HF with signs and symptoms of systemic or pulmonary congestion

Recommendation

Clinical Circumstances

(a) Hospitalization Recommended

Evidence of severely decompensated HF, including:

Hypotension
Worsening renal function
Altered mentation

Dyspnea at rest

Typically reflected by resting tachypnea
Less commonly reflected by oxygen saturation <90%

Hemodynamically significant arrhythmia

Including new onset of rapid atrial fibrillation

Acute coronary syndromes

(b) Hospitalization Should be Considered

Worsened congestion

Even without dyspnea
Typically reflected by a weight gain of >5 kg

Signs and symptoms of pulmonary or systemic congestion

Even in the absence of weight gain

Major electrolyte disturbance

Associated comorbid conditions

Pneumonia
Pulmonary embolus
Diabetic ketoacidosis
Symptoms suggestive of transient ischemic accident or stroke

Repeated implantable cardioverter defibrillators (ICD) firings

Previously undiagnosed HF with signs and symptoms of systemic or pulmonary congestion

Table 12.2: Signs and Symptoms of Congestion in HF

	Pulmonary	Systemic
Symptoms	Dyspnea	Edema
	Orthopnea	Abdominal (or hepatic) swelling and pain
	Paroxysmal nocturnal dyspnea (PND)
Signs	Rales	Edema
	Wheezing	Elevated jugular venous pressure (JVP)
	Pleural effusion	Hepatic enlargement and tenderness
	Hypoxemia	Ascites
	Third heart sound (left-sided)*	Third heart sound (right-sided)*
	Worsening mitral regurgitation	Worsening tricuspid regurgitation Hepatojugular reflux

* May occur without congestion

It is recommended that patients admitted with ADHF be treated to achieve the goals listed in the Table 12.3, below. (Strength of Evidence = C)

Table 12.3: Treatment Goals for Patients Admitted for ADHF

Improve symptoms, especially congestion and low-output symptoms
Optimize volume status
Identify etiology (see Table 4.6 in the National Guideline Clearinghouse (NGC) summary of the Heart Failure Society of American (HFSA) guideline Evaluation of Patients for Ventricular Dysfunction and Heart Failure)
Identify precipitating factors
Optimize chronic oral therapy
Minimize side effects
Identify patients who might benefit from revascularization
Educate patients concerning medications and self assessment of HF
Consider and, where possible, initiate a disease management program

Patients admitted with ADHF should be carefully monitored. It is recommended that the items listed in Table 12.4, below, be assessed at the stated frequencies. (Strength of Evidence = C)

Table 12.4: Monitoring Recommendations for Patients Hospitalized With ADHF

Frequency	Value	Specifics
At least daily	Weight	Determine after voiding in the morning Account for possible increased food intake due to improved appetite
At least daily	Fluid intake and output
More than daily	Vital signs	Including orthostatic blood pressure
At least daily	Signs	Edema Ascites Pulmonary rales Hepatomegaly Increased jugular venous pressure (JVP) Hepatojugular reflux Liver tenderness
At least daily	Symptoms	Orthopnea Paroxysmal nocturnal dyspnea (PND) Nocturnal cough Dyspnea Fatigue
At least daily	Electrolytes	Potassium Sodium
At least daily	Renal function	Blood urea nitrogen (BUN) Serum creatinine*

See background section in the original guideline document for additional recommendations on laboratory evaluations.

Routine and frequent laboratory tests recommended in ADHF are shown in Table 12.5, below.

Table 12.5: Laboratory Evaluation for Patients With ADHF

Routinely	Electrolytes BUN and creatinine Blood glucose Troponin Complete blood count International normalized ratio (INR) if using Coumadin Oxygen saturation
Frequently	BNP or NT-proBNP Liver function tests Urinalysis D-dimer Arterial blood gases

Careful repeated assessment of signs and symptoms of congestion and changes in body weight is recommended, because clinical experience suggests it is difficult to determine that congestion has been adequately treated in many patients. (Strength of Evidence = C)

Monitoring of daily weights, intake, and output is recommended to assess clinical efficacy of diuretic therapy. Routine use of a Foley catheter is not recommended for monitoring volume status. However, placement of a catheter is recommended when close monitoring of urine output is needed. (Strength of Evidence = C)

Careful observation for development of a variety of side effects, including renal dysfunction, electrolyte abnormalities, and symptomatic hypotension, is recommended in patients treated with diuretics, especially when used at high doses and in combination. Patients should undergo routine laboratory studies and clinical examination as dictated by their clinical response. (Strength of Evidence = C)

Serum potassium and magnesium levels should be monitored at least daily and maintained in the normal range. More frequent monitoring may be necessary when diuresis is rapid. (Strength of Evidence = C)

Overly rapid diuresis may be associated with severe muscle cramps, which should be treated with potassium replacement if indicated. (Strength of Evidence = C)

Careful observation for the development of renal dysfunction is recommended in patients treated with diuretics. Patients with moderate to severe renal dysfunction and evidence of fluid retention should continue to be treated with diuretics. In the presence of severe fluid overload, renal dysfunction may improve with diuresis. (Strength of Evidence = C)

When congestion fails to improve in response to diuretic therapy, the following options should be considered:

Sodium and fluid restriction
Increasing doses of loop diuretic
Continuous infusion of a loop diuretic, or
Addition of a second type of diuretic orally (metolazone or spironolactone) or intravenously (chlorothiazide).

A fifth option, ultrafiltration, may be considered. (Strength of Evidence = C)

A low sodium diet (2 g daily) is recommended, as is supplemental oxygen as needed for hypoxemia. (Strength of Evidence = C)

In patients with recurrent or refractory volume overload, stricter sodium restriction may be considered. (Strength of Evidence = C)

Fluid restriction (<2 L/day) is recommended in patients with moderate hyponatremia (serum sodium <130 mEq/L) and should be considered to assist in treatment of fluid overload in other patients. (Strength of Evidence = C)

In patients with severe (serum sodium <125 mEq/L) or worsening hyponatremia, stricter fluid restriction may be considered. (Strength of Evidence = C)

Routine administration of supplemental oxygen in the absence of hypoxia is not recommended. (Strength of Evidence = C)

In the absence of symptomatic hypotension, intravenous nitroglycerin, nitroprusside, or nesiritide may be considered as an addition to diuretic therapy for rapid improvement of congestive symptoms in patients admitted with ADHF. (Strength of Evidence = B) Frequent blood pressure monitoring is recommended with these agents. (Strength of Evidence = B)

These agents should be decreased in dosage or discontinued if symptomatic hypotension develops. (Strength of Evidence = B) Reintroduction in increasing doses may be considered once symptomatic hypotension is resolved. (Strength of Evidence = C)

Intravenous vasodilators (intravenous nitroglycerin or nitroprusside) and diuretics are recommended for rapid symptom relief in patients with acute pulmonary edema or severe hypertension. (Strength of Evidence = C)

Intravenous vasodilators (nitroprusside, nitroglycerin, or nesiritide) may be considered in patients with ADHF and advanced HF who have persistent severe HF despite aggressive treatment with diuretics and standard oral therapies. (Strength of Evidence = C)

Intravenous inotropes (milrinone or dobutamine) may be considered to relieve symptoms and improve end-organ function in patients with advanced HF characterized by left ventricular (LV) dilation, reduced left ventricular ejection fraction (LVEF), and diminished peripheral perfusion or end-organ dysfunction (low output syndrome), particularly if these patients have marginal systolic blood pressure (<90 mm Hg), have symptomatic hypotension despite adequate filling pressure, or are unresponsive to, or intolerant of, intravenous vasodilators. (Strength of Evidence = C)

These agents may be considered in similar patients with evidence of fluid overload if they respond poorly to intravenous diuretics or manifest diminished or worsening renal function. (Strength of Evidence = C)

When adjunctive therapy is needed in other patients with ADHF, administration of vasodilators should be considered instead of intravenous inotropes (milrinone or dobutamine). (Strength of Evidence = B)

Intravenous inotropes (milrinone or dobutamine) are not recommended unless left heart filling pressures are known to be elevated based on direct measurement or clear clinical signs. (Strength of Evidence = B)

Administration of intravenous inotropes (milrinone or dobutamine) in the setting of ADHF should be accompanied by continuous or frequent blood pressure monitoring and continuous monitoring of cardiac rhythm. (Strength of Evidence = C)

If symptomatic hypotension or worsening tachyarrhythmias develop during administration of these agents, discontinuation or dose reduction should be considered. (Strength of Evidence = C)

The routine use of invasive hemodynamic monitoring in patients with ADHF is not recommended. (Strength of Evidence = A)

Invasive hemodynamic monitoring should be considered in a patient:

Who is refractory to initial therapy
Whose volume status and cardiac filling pressures are unclear
Who has clinically significant hypotension (typically systolic blood pressure [SBP] <80mm Hg) or worsening renal function during therapy, or
In whom documentation of an adequate hemodynamic response to the inotropic agent is necessary when chronic outpatient infusion is being considered. (Strength of Evidence = C)

It is recommended that every effort be made to use the hospital stay for assessment and improvement of patient compliance via patient and family education and social support services (see the NGC summary of the HFSA guideline Disease Management in Heart Failure). (Strength of Evidence = C)
It is recommended that criteria in Table 12.7, below, be met before a patient with HF is discharged from the hospital. (Strength of Evidence = C)
In patients with advanced HF or recurrent admissions for HF, additional criteria listed in Table 12.7, below, should be considered. (Strength of Evidence = C)

Table 12.7: Discharge Criteria for Patients With HF

Recommended for all HF Patients

Exacerbating factors addressed.
At least near optimal volume status achieved.
Transition from intravenous to oral diuretic successfully completed.
Patient and family education completed.
At least near optimal pharmacologic therapy achieved (see the NGC summaries of the HFSA guidelines Heart Failure in Patients with Left Ventricular Systolic Dysfunction and Evaluation and Management of Patients with Heart Failure and Preserved Left Ventricular Ejection Fraction)
Follow-up clinic visit scheduled, usually for 7 to 10 days

Should be considered for patients with advanced HF or recurrent admissions for HF

Oral medication regimen stable for 24 hours
No intravenous vasodilator or inotropic agent for 24 hours
Ambulation before discharge to assess functional capacity after therapy
Plans for postdischarge management (scale present in home, visiting nurse or telephone follow up generally no longer than 3 days after discharge)
Referral for disease management

Discharge planning is recommended as part of the management of patients with ADHF. Discharge planning should address the following issues:
- Details regarding medication, dietary sodium restriction, and recommended activity level
- Follow-up by phone or clinic visit early after discharge to reassess volume status
- Medication and dietary compliance
- Monitoring of body weight, electrolytes and renal function
- Consideration of referral for formal disease management (Strength of Evidence = C)

Definitions:

Strength of Evidence

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

Strength of Recommendations

"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

CLINICAL ALGORITHM(S)

None provided

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EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

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.

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IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

Heart Failure Society of America. Evaluation and management of patients with acute decompensated heart failure. J Card Fail 2006 Feb;12(1):e86-103. [80 references] PubMed

ADAPTATION

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

DATE RELEASED

1999 (revised 2006 Feb)

GUIDELINE DEVELOPER(S)

Heart Failure Society of America, Inc - Disease Specific Society

SOURCE(S) OF FUNDING

Heart Failure Society of America, Inc

GUIDELINE COMMITTEE

Comprehensive Heart Failure Practice Guideline Committee

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

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

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

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).

GUIDELINE STATUS

This is the current release of the guideline.

GUIDELINE AVAILABILITY

Electronic copies: Available from the Heart Failure Society of America, Inc. Web site.

Print copies: Available from the Heart Failure Society of America, Inc., Court International - Suite 240 S, 2550 University Avenue West, Saint Paul, Minnesota 55114; Phone: (651) 642-1633

AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

Heart Failure Society of America. Executive summary: HFSA 2006 comprehensive heart failure practice guideline. J Card Fail 2006 Feb;12(1):10-38.

Heart Failure Society of America. Development and implementation of a comprehensive heart failure practice guideline. J Card Fail 2006 Feb;12(1):e3-9.

Heart Failure Society of America. Conceptualization and working definition of heart failure. J Card Fail 2006 Feb;12(1):e10-11.
Electronic copies: Available from the Heart Failure Society of America, Inc. Web site.
PowerPoint slides. HFSA 2006 comprehensive heart failure guideline.
Electronic copies: Available from the Heart Failure Society of America, Inc. Web site.

The following is also available:

Heart Failure Society of America. Pocket guide. HFSA 2006 comprehensive heart failure practice guideline.

Electronic copies: Not available at this time.

Print copies: Available from the Heart Failure Society of America, Inc., Court International - Suite 240 South, 2550 University Avenue West, Saint Paul, Minnesota 55114; Phone: (651) 642-1633

PATIENT RESOURCES

None available

NGC STATUS

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.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please direct inquiries to info@hfsa.org.

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Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

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Readers with questions regarding guideline content are directed to contact the guideline developer.

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Brief Summary

GUIDELINE TITLE

BIBLIOGRAPHIC SOURCE(S)

GUIDELINE STATUS

REGULATORY ALERT

FDA WARNING/REGULATORY ALERT

BRIEF SUMMARY CONTENT

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

CLINICAL ALGORITHM(S)

EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

ADAPTATION

DATE RELEASED

GUIDELINE DEVELOPER(S)

SOURCE(S) OF FUNDING

GUIDELINE COMMITTEE

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

GUIDELINE STATUS

GUIDELINE AVAILABILITY

AVAILABILITY OF COMPANION DOCUMENTS

PATIENT RESOURCES

NGC STATUS

COPYRIGHT STATEMENT

DISCLAIMER

NGC DISCLAIMER

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