This guideline will primarily focus on acute decompensated heart failure with some references to stable heart failure management.
- Heart failure is a complex clinical syndrome identified by characteristic symptoms such as dyspnoea and fatigue where structural or functional impairment of the heart reduces ventricular filling or ejection of the blood.
- Based on left ventricular ejection fractions heart failure can be classified into two types:
- Heart failure with reduced ejection fraction (HFrEF) LVEF <40%
- Heart failure with preserved ejection fraction (HFpEF) LVEF >50%
- Acute decompensated heart failure (ADHF) is a clinical syndrome of new or worsening symptoms of heart failure often leading to hospitalisation or presentation to the emergency department.
- Acute cardiogenic pulmonary oedema is often the result of ADHF and occurs with liquid accumulation in the tissues and air spaces of the lung.
- Heart failure is usually caused by myocardial damage
- The goal of management is the identification and reversal of causes and precipitating factors
- All patients with heart failure should have an inpatient or outpatient transthoracic echocardiogram
- The treatment for heart failure with reduced left ventricular ejection fraction (HFrEF) and heart failure with preserved left ventricular ejection fraction (HFpEF) are different.
Triage (2) #
Triaging acute decompensation of heart failure will depend on various different factors, including the patient’s premorbid degree of heart failure, severity of the acute exacerbation and other clinical features. If a patient is hypoxic, hypotensive or tachypnoeic they should be seen immediately. Otherwise in 1 hour is appropriate.
Causes (3) #
Aetiology of Heart Failure
- Coronary artery disease
- Excess alcohol intake
- Valvular heart disease
- Chronic lung disease
- Dilated: ETOH, valvular disease
- Restrictive: infiltrative heart disease e.g. amyloidosis, sarcoidosis, haemochromatosis (rarer)
Precipitants for ADHF
A useful mnemonic to remember some precipitants of ADHF is MADHATTER3P
- Myocardial infarction
- Drugs (NSAIDs, negative inotropes, compliance)
- Thyrotoxicosis or hypothyroidism
- Renal failure/rupture of chordae
Precipitants divided by system
- Myocardial ischemia or infarction
- Pericardial tamponade
- Acute valvular dysfunction
- Arrhythmias (including tachyarrhythmias and heart blocks)
- Lack of adherence to drug therapy
- Negatively inotropic drugs (e.g. beta-blockers, central CCB etc.)
- Triple whammy ( ACE inhibitor, NSAID, diuretic) -> AKI-> HF
- Causes of hypoxia such as pulmonary embolism
- Thyrotoxicosis or hypothyroidism
- Renal failure
- Electrolyte abnormalities
Clinical features #
It is important to determine which symptoms occur at baseline and which are new onset
|General symptoms of heart failure||Symptoms of left heart failure||Symptoms of right heart failure|
|FatigueReduced exercise tolerance||DyspnoeaOrthopnoeaParoxysmal nocturnal dyspnoea Nocturnal cough, pink frothy sputum||Peripheral pitting oedema|
- Primary survey
- A: ensure patient can maintain own airway
- B: tachypnoea, hypoxia, increased work of breathing
- C: tachycardia, poor peripheral perfusion, hypotension
- D: confusion and altered mental status
|General signs of heart failure||Signs of left heart failure||Signs of right heart failure|
|S3 heart sound||Bilateral basilar crackles audible on auscultationLaterally displaced apical heartbeat||Elevated JVPPeripheral pitting oedema Hepatojugular reflux ( manual pressure over the liver leads to visible JVP distention for several seconds)|
|ECG||Investigate any precipitating arrhythmias, atrioventricular blocks and evidence of current or previous myocardial infarction|
|Troponin*||Most patients with acute heart failure will have an elevated troponin but consider concurrent AMI|
|Chest X-ray||Investigate pleural effusion, pulmonary oedema, pericardial effusion and cardiomegaly|
|Echocardiogram*||Used to identify left ventricular ejection fraction and determine an underlying cause|
|FBE||May show anaemia and infection|
|UEC||Useful to check renal functions before starting nephrotoxic cardiac medications and the presence of AKI|
|Septic screen*||May be useful to rule out an infectious precipitant and infectious differentials|
|VBG/ABG||Used to identify metabolic acidosis with raised lactate demonstrating poor tissue perfusion|
|BNP*||Has a negative predictive value and can rule out heart failure. Not useful if the patient has a known past diagnosis of heart failure and presents with similar symptoms.|
|COVID Swab||Used to rule out COVID-19 as a diagnosis as may have similar symptoms to ADHF|
|TFTs*||Used to rule out a thyroid cause of heart failure if high suspicion|
|D dimer*||Used to rule out a PE cause of heart failure|
Consider the New York Heart Association (NYHA) functional classification of heart failure to determine baseline before exacerbation(3-5).
|New York Heart Association (NYHA) Classification||Symptoms|
|I||No limitations in normal physical activity|
|II||Mild symptoms only in normal activity|
|III||Marked symptoms during daily activities, asymptomatic only at rest|
|IV||Severe limitations, symptoms even at rest|
Heart failure can be classified into two categories based on left ventricular ejection fraction. Heart failure with reduced ejection fraction (HFrEF) occurs when the left ventricular ejection fraction (LVEF) is lesser than >40% whereas heart failure with preserved ejection fraction HFpEF has a LVEF <50%.
The medications used for long term management of HFrEF have not been studied for outcomes in HFpEF but may be used based on indication due to concurrent morbidities. In terms of ADHF some of the initial therapies are different for HFrEF and HFpEF. Beta blockers generally should be used with caution in the acute setting in patients with HFrEF. In contrast, in HFpEF treatment of hypertension and tachycardia is particularly important.
Initial management of ADHF #
Consider whether the patient has an advance care directive in place which may guide goals of care. A good mnemonic to remember some treatments (not in order or priority) of heart failure is LMNOP(2,3,5-9).
- Lasix (furosemide)
- Nitrates (glyceryl trinitrate)
- Positioning (ensure the patient elevated and not lying flat)
The most important aim of treating ADHF after resuscitation is identifying the precipitant and reversing any reversible causes from the precipitants section of this factsheet.
First line therapy for all patients
|Furosemide 20 to 80 mg* intravenously, repeated 20 minutes later if necessary.|
Strict fluid and sodium restriction
Supplemental oxygen therapy if SpO2 <94%
Continuous monitoring of:ECGBlood pressurePulse oximetry
|*A rule of thumb is that IV furosemide is twice as effective as oral furosemide and to give the patient at least 2.5 times their normal dose of furosemide if they were taking it. Beware when giving furosemide in patients with HF secondary to pericardial effusion/ cardiac tamponade|
Consider for all patients
Glyceryl trinitrate* Glyceryl trinitrate spray 400 micrograms sublingually; repeat the dose every 5 minutes up to maximum 1200 microgramsORGlyceryl trinitrate tablet 300 to 600 micrograms sublingually; repeat the dose every 5 minutes up to maximum 1800 micrograms.Consider starting a glyceryl trinitrate infusion
Morphine 1 to 2.5 mg intravenously, as a single dose to help relieve distress. For older patients use the lower range dose of morphine. Monitor conscious state through a sedation score.Indwelling catheter to monitor urine output
|* Use with caution in patients with systolic blood pressure below 100 mmHg, symptomatic hypotension or signs of poor perfusion. Beware in patients with inferior myocardial infarction precipitating ADHF. This will decrease blood pressure since they are preload dependent.|
Second line therapy for all patients
|Referral to ICU for further advice|
Continuous positive airway pressure ventilation (CPAP)*
Consider adding dobutamine*
Intubation if unresponsive to above treatments*
|*These treatments would require the support of ICU and specialists and are beyond the scope of this factsheet|
Ongoing hospital management #
For all patients with HF (2,3,5-9)
|Fluid restriction||Daily weightsStrict fluid balanceStrict fluid restriction|
|Sodium restriction||Salt restriction (dietician referral)|
|Other||Avoid cardiotoxic medicationsManaging night time symptoms with bed elevation or extra pillows VTE prophylaxisCardiac rehabilitation|
|Monitoring for cardiorenal syndrome||Consultation with nephrology Daily UEC and consider CMPAvoidance of nephrotoxic medication other than diuretics|
For all patients with HFrEF
|First Line:||Angiotensin converting enzyme inhibitor (ACEI)* starting at a low dose and titrating upwards to the highest tolerated dose within the recommended range. ACEI have been showed to improve prognosis and symptoms. Only one type of ACEI is listed as an example. Ramipril 2.5 mg orally, twice daily, increasing to maximum 5 mg twice daily|
Beta blockers** starting at a low dose and slowly increasing aiming for the highest tolerated dose within the recommended range. The beta blockers listed below have been shown to improve clinical outcomes in HFrEF.
Bisoprolol 1.25 mg orally, daily, increasing to maximum 10 mg dailyOR Carvedilol less than 85 kg: 3.125 mg orally, twice daily, increasing to maximum 25 mg twice daily
more than 85 kg: 3.125 mg orally, twice daily, increasing to maximum 50 mg twice daily
ORMetoprolol succinate modified-release 23.75 mg orally, daily, increasing to maximum 190 mg dailyOR
Nebivolol 1.25 mg orally, daily, increasing to maximum 10 mg daily.
|Second Line:||Angiotensin II receptor blocker (ARB)* is used if patients are unable to tolerate an ACEI starting at a low dose and titrating upwards to the highest tolerated dose within the recommended range. An ARB should not be used concurrently as an ACEI. ARBs have been shown to improve prognosis and symptoms. Only one type of ARB is listed as an example.|
Candesartan 4 mg orally, daily, increasing to maximum 32 mg daily
Consider aldosterone antagonists*** for HFrEF. Start with a low dose and consider increasing the dose if signs and symptoms of heart failure persist. Aldosterone antagonists have been shown to improve survival and reduce hospitalisations.
Spironolactone 25 mg orally, daily, increasing to 50 mg daily if required
Consider loop diuretics**** in HFrEF to reduce the signs and symptoms of congestion. Start with the following doses and titrate to effect. Loop diuretics have not been shown to reduce mortality or morbidity.
Furosemide (frusemide) 20 to 40 mg orally, daily
Bumetanide 0.5 to 1 mg orally, daily
Etacrynic acid 50 mg orally, daily.
|* ACEI and ARB therapy requires frequent monitoring for hypotension, kidney impairment and hyperkalaemia.** Beta blockers can initially worsen heart failure and to minimise these complications:do not initiate beta-blocker therapy during a period of acute decompensationmonitor the patient’s symptoms frequently and measure weight dailyavoid simultaneous addition of vasodilator drugs.*** Monitor for life threating hyperkalaemia when combining an aldosterone antagonist with an ACEI or ARB in a patient with kidney impairment **** Beware of a rising serum creatinine and reduce the diuretic dose and monitor weight, kidney function and electrolytes closely if that occurs. Avoid prescribing patients with an ACEI, NSAID and a loop diuretic ( triple whammy) as that can significantly decrease kidney function.|
For all patients with HFpEF
|Consider||ACEI therapy ( which is often indicated for a comorbidity) starting at a low dose and titrating upwards to the highest tolerated dose within the recommended range. Only one type of ACEI is listed as an example. ACEI may have beneficial effects but there is insufficient evidence to recommend routine ACEI therapy in all patients with HFpEF. Ramipril 2.5 mg orally, twice daily, increasing to maximum 5 mg twice daily|
Beta blocker therapy starting at a low dose and titrating upwards to the highest tolerated dose within the recommended range. Only one type of beta blocker is listed as an example. Beta blocker therapy may be beneficial particularly in patients with atrial fibrillation or coexisting ischaemic heart disease.
Bisoprolol 1.25 mg orally, daily, increasing to maximum 10 mg daily
|Avoid||Diuretics as excess diuresis can lead to severe reduction in cardiac output and blood pressure|
Discharge planning for all patients with HF
|Reduction of risk factors||Smoking cessation Avoidance of excess alcohol Weight reductionRegular physical exercise Education regarding self-management of heart failureManagement of heart failure comorbidities Advice to receive flu and pneumococcal vaccines|
|Follow up||Referral to a multidisciplinary heart failure disease management program|
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Reviewing Consultant/Senior Registrar
Dr Bowen Xia
Dr Robert Stolz