Treatment Guideline Chart
Heart failure is a clinical syndrome caused by functional or structural impairment of ventricular filling or blood ejection.
It is characterized by either left ventricular hypertrophy or dilation or both.
It leads to neurohormonal and circulatory abnormalities.
Acute heart failure is the rapid onset of or change in the signs and symptoms of heart failure.
It arises as a result of cardiac function deterioration in patients previously diagnosed with heart failure or may also be the first presentation of heart failure.
It is characterized by pulmonary congestion, decreased cardiac output and tissue hypoperfusion.
It is a life-threatening condition that needs immediate medical attention.

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  • The diagnosis of acute heart failure is based on clinical findings supported by appropriate diagnostic exam performed urgently after first patient contact; identifies patients in cardiogenic shock and respiratory failure


Clinical Conditions of Acute Heart Failure

Patients with acute heart failure may present in one of the following clinical categories

Worsening or Decompensated Heart Failure

  • Usually with a history of progressive worsening of chronic heart failure on treatment and evidence of systemic and pulmonary congestion
  • Hypotension on admission is associated with a poor prognosis

Pulmonary Edema

  • Patients present with severe respiratory distress, tachypnea, orthopnea and with rales over the lung fields
  • Arterial O2 saturation is usually <90% on room air prior to oxygen therapy
  • Confirmed by chest radiography

Hypertensive Heart Failure

  • Signs and symptoms of heart failure accompanied by high blood pressure and preserved left ventricular function (heart failure with preserved ejection fraction)
  • Evidence of increased sympathetic tone with tachycardia and vasoconstriction
  • May be mildly hypervolemic or euvolemic with signs of pulmonary congestion without signs of systemic congestion
  • Rapid response to appropriate treatment and low hospital mortality

Cardiogenic Shock

  • Tissue hypoperfusion induced by heart failure after adequate correction of preload and major arrhythmia
  • Characterized by reduced systolic blood pressure (SBP <90 mmHg or a decrease of mean arterial pressure >30 mmHg) and absent or low urine output of <0.5 mL/kg/hr
  • Rhythm disturbance is common
  • Pulmonary congestion and organ hypoperfusion develop rapidly
  • There is continuum from low cardiac output syndrome to cardiogenic shock

Isolated Right Heart Failure

  • Low output syndrome in the absence of pulmonary congestion with elevated jugular venous pressure, with or without hepatomegaly and low left ventricular filling pressures

Acute Coronary Syndrome (ACS) and Heart Failure

  • Some patients with acute coronary syndrome present with symptoms and signs of heart failure
  • Episodes of heart failure are associated with or precipitated by arrhythmia
  • Patients are managed according to the ACS guidelines

Acute Mechanical Causes

  • Conditions include acute incompetence of the native or prosthetic valve due to endocarditis, aortic dissection or thrombosis, cardiac intervention or chest trauma

Physical Examination

  • Vital signs (eg low or high blood pressure, bradycardia, tachycardia with pulsus alternans, irregular pulse, tachypnea, increased work of breathing, apnea or hypopnea with respiratory rate <8 breaths/minute despite dyspnea, intolerance of supine position) and patient's body mass index
    • Assess hemodynamic status, heart rhythm and level of dyspnea to determine degree of cardiopulmonary instability
    • Check for murmurs, laterally displaced or prominent apex beat, S3 gallop and accentuated pulmonic component of the 2nd heart sound
  • Hypoperfusion: Low output state usually caused by pump failure (eg cold sweated extremities, oliguria, narrow pulse pressure, altered mental status, dizziness, capillary refill time >2 seconds)
    • Often accompanied by but is not synonymous with hypotension
  • Congestion: Left-sided [bilateral pulmonary rales, bilateral peripheral edema (eg ankle, sacral, scrotal)] or right-sided (elevated jugular venous pressure, bilateral peripheral edema, hepatomegaly, ascites, hepatojugular reflux) volume overload
  • Based on the physical exam, acute heart failure can be classified based on the presence or absence of congestion and/or hypoperfusion
    • Warm-dry: Both congestion and hypoperfusion are absent
    • Warm-wet: Congestion present but without hypoperfusion
    • Cold-dry: Hypoperfusion present but without congestion
    • Cold-wet: Both congestion and hypoperfusion are present

Laboratory Tests

  • Complete blood count (CBC), serum electrolytes, blood urea nitrogen (BUN), creatinine/estimated glomerular filtration rate (GFR), glucose, troponin, uric acid, calcium, magnesium, albumin, lipid profile, liver enzymes, bilirubin, ferritin, transferrin saturation (TSAT), total iron-binding capacity (TIBC), cardiac enzymes, thyroid function tests, international normalized ratio (INR), C-reactive protein (CRP), D-dimer and urinalysis
    • To detect reversible/treatable causes of heart failure and presence of other co-morbidities
  • Plasma natriuretic peptide [eg B-type natriuretic peptide (BNP), N-terminal pro-BNP (NT-proBNP), mid-regional pro atrial natriuretic peptide (MR-proANP)]
    • Acute heart failure is associated with increased plasma levels of natriuretic peptides
      • Thresholds: BNP <100 pg/mL, NT-proBNP <300 pg/mL, MR-proANP <120 pg/mL
    • Recommended upon presentation in patients who are suspected to have heart failure, especially when the diagnosis is uncertain, also to exclude other causes of dyspnea
    • May be utilized to establish prognosis of heart failure on admission and predischarge  
    • May also be used to screen individuals at risk of developing heart failure 
  • Measure cardiac biomarkers [eg cardiac troponin T (cTNT), highly sensitive troponin T (HsTNT)] in patients who present with acute decompensated heart failure

Other Diagnostic Tests 

  • Electrocardiogram (ECG)
    • To assess cardiac rate and rhythm, conduction, electrical dyssynchrony, chamber enlargement, QTc interval and detect presence of myocardial infarction or ischemia; has a high negative predictive value
    • Performed immediately in patients with suspected cardiogenic shock
  • Exercise testing
    • To detect the presence of reversible ischemia 
    • Allows objective evaluation of exertional symptoms and exercise capacity to aid in prescribing an exercise training program
    • Aids in the evaluation of patients for heart transplantation and mechanical circulatory support and to obtain prognostic information
  • Endomyocardial biopsy
    • May be used in patients with rapidly progressive clinical heart failure or ventricular dysfunction despite appropriate medical treatment and those who are suspected of having myocarditis or infiltrative diseases


  • Chest radiography
    • To rule out other non-cardiac causes of dyspnea and to evaluate heart size, presence of congestion, pulmonary or other diseases and proper placement of implanted cardiac devices
      • Specific findings for acute heart failure include cardiomegaly, pulmonary venous congestion, pleural effusion and interstitial or alveolar edema
  • Echocardiography
    • To determine cardiac structure and function 
    • Method of choice in patients with suspected heart failure because of its accuracy, availability, safety and cost
      • Consider doing within 48 hours of admission for early management guidance if patient is hemodynamically unstable and after stabilization particularly with de novo disease; performed immediately in patients with suspected cardiogenic shock
    • May be performed if natriuretic peptide levels are elevated to rule out cardiac abnormalities
  • Coronary angiography
    • To evaluate the coronary anatomy [ie establishes the presence and extent of coronary artery disease (CAD)]
    • Recommended in patients with angina pectoris and patients with cardiogenic shock who are suitable for coronary revascularization
    • A multidetector computed tomography (MDCT) study may be used as an alternative to invasive coronary angiography in select patients to rule out significant CAD
  • Cardiac catheterization
    • To evaluate patients for heart transplantation or mechanical circulatory support
    • To assess right and left heart function and pulmonary arterial resistance
  • Cardiac magnetic resonance (CMR) imaging
    • To evaluate cardiac structure and function
    • To characterize cardiac tissue, especially in patients with inadequate echocardiographic images or inconclusive echocardiographic findings
  • Myocardial perfusion/ischemia imaging [eg echocardiography, CMR, single photon emission computed tomography (SPECT), or positron emission tomography (PET)]
    • To assess the presence of reversible myocardial ischemia and viable myocardium 
    • Should be considered in patients who are suspected to have CAD and who are suitable for coronary revascularization
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