Treatment Guideline Chart
Heart failure is a clinical syndrome due to a structural or functional cardiac abnormality that impairs the ability of the ventricle to fill with or eject blood in order to deliver oxygen at a rate commensurate with the requirements of the metabolizing tissues in spite of normal filling pressures or only at the expense of elevated filling pressures.
Symptoms are caused by ventricular dysfunction secondary to abnormalities of the myocardium, pericardium, endocardium, valves, heart rhythm or conduction.
Chronic heart failure is a chronic state where patient's signs and symptoms have been unchanged (stable) for at least a month but may decompensate suddenly or slowly when stable chronic heart failure deteriorates leading to hospitalization or outpatient IV diuretic therapy.

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  • Pneumococcal vaccination and annual influenza vaccination, as well as COVID-19 vaccination, are recommended in all patients with HF in the absence of known contraindication
  • Pulmonary congestion and pulmonary hypertension increase the risk of respiratory infections (one of the major causes of acute decompensation, especially in the elderly)


  • Assessment of prognosis provides better information for the patients and their families to plan for their futures
    • Validated multivariable risk scores for CHF (eg the Seattle Heart Failure Model, the Heart Failure Survival score and the Meta-analysis Global Group in Chronic Heart Failure [MAGGIC] score) have commonly been used to provide estimates of patient’s survival 
  • Helps in the identification of patients in whom cardiac transplantation or mechanical device therapy should be considered  
  • Patients with HF, even with stable and well-controlled symptoms, require follow-up at intervals no longer than 6 months to assess symptoms and treatment optimization
    • A follow-up visit 1-2 weeks after hospitalization (earlier [within 7 days] if admitted for worsening HF) is recommended to check for signs of congestion, drug tolerance and to initiate and/or uptitrate evidence-based therapy
  • Patients with prior HFrEF who currently have an LVEF of >40% are considered to have an improved LVEF (HFimpEF) and should continue optimized GDMT, even in those who may become asymptomatic, in order to avoid LV dysfunction and relapse of HF
  • Referral to a HF specialist should be considered in patients needing chronic IV inotropes, with NYHA Class IIIB/IV symptoms or persistently elevated natriuretic peptides, end-organ dysfunction, EF ≤35%, defibrillator shocks, multiple hospitalizations, edema despite dose escalation of diuretics, low systolic BP/high heart rate, and progressive intolerance or down-titration of GDMT
    • Other indications for referral of advanced HF include a new-onset HF regardless of EF, CHF with high-risk features, HF etiology requiring a second opinion, yearly review of patients with confirmed advanced HF and patient assessment for possible clinical trial inclusion
  • Provide palliative and end-of-life care services to patients with advanced HF

Conditions Associated with a Poor Prognosis in Heart Failure

  • Advanced age
  • Ischemic etiology
  • Worsening NYHA functional status (Class III-IV)
  • Chronic hypotension
  • Resting tachycardia
  • Intolerance to GDMT at optimal dose
  • Increasing need for diuretics, refractory volume overload
  • >1 HF hospitalization within the last year
  • Resuscitated sudden death, CRT non-responder clinically
  • Decreasing peak exercise O2 uptake
  • Iron deficiency with or without anemia
    • Anemia is independently associated with the severity of HF and iron deficiency seems to be uniquely associated with a reduction in exercise capacity
      • Iron deficiency in HF patients is associated with a worse prognosis
  • Progressive deterioration of hepatic or renal function
  • Persistent hyponatremia
  • Marked elevation of brain-type natriuretic peptide (BNP)/N-terminal-pro-BNP (NT-proBNP)
  • Elevated biomarkers of myocardial fibrosis (soluble ST2 receptor, galectin-3, high sensitivity cardiac troponin) and neurohormonal activation
  • Widened QRS >120 msec on 12-lead ECG
  • Tachycardia and Q waves
  • LVH and complex ventricular arrhythmias
  • Decreasing LVEF
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