CLINICAL CLASSIFICATION TYPICAL TRIGGERS
Acute Decompensation of Patient with chronic
Chronic HF (most common) compensated HF who
gradually decompensates
due to non-compliance to
meds, ischemia, or infections
Acute Hypertensive HF Patient with no HF suddenly
decompensates
Possibly causes:
hypertensive emergency,
arrhythmias, or ACS
Cardiogenic Shock Patient with progression of
advanced HF or a patient
who develops a major
myocardial insult (large MI,
acute myocarditis)
SIGNS AND SYMPTOMS CLINICAL ASSESSMENT
Peripheral edema SBP: generally in the normal
Orthopnea dyspnea on range
exertion CXR: often clear despite
Usually no/minimal volume elevated filling pressures
overload ECHO: preserved or reduced
EF
Dyspnea (severe) SBP: >140 (most)
Tachypnea CXR: often clear pulmonary
Tachycardia edema
Frank pulmonary edema ECHO: preserved EF (most)
Hypoxemia common
End-organ hypoperfusion SBP: low or low-normal
Oliguria Echo: severely depressed EF
Confusion Evidence of end-organ
Cool extremities dysfunction (renal, hepatic)
PHASE 1: URGENT/EMERGENT CARE

The initial goals in the management of a patient

presenting with AHF are to:

• Expeditiously establish the diagnosis

• Treat life-threatening abnormalities
• Initiate therapies to rapidly provide symptom relief
• Identify the etiology and precipitating triggers for the
episode of AHF
 PHASE 1: URGENT/EMERGENT CARE

Profile Description Management

Warm and Dry Good perfusion and no congestion Adjust oral therapy (since patient is adequately
perfused and compensated)

Warm and Wet Good perfusion but with congestion If hypertension predominates:
- Vasodilators and diuretics
If congestion predominates:
- Vasodilators and diuretics

Cold and Dry With hypoperfusion but no congestion Consider fluid challenge first, then inotropic support if
it is still hypo perfused

Cold and Wet With hypoperfusion and with congestion If SBP >90 mmHg: vasodilators, diuretics, consider
inotropic agents if refractory If SBP
 PHASE 1: URGENT/EMERGENT CARE

DRUG CLASS REMARKS

Diuretics First-line therapy in volume overloaded patients with pulmonary congestion
Vasodilators Initial therapy for hypertensive AHF
Used for patients with pulmonary congestion for rapid relief of dyspnea
BP should be normal
Dual benefit: - Decreases venous tone to optimize preload - Decreases arterial tone
(or afterload)
Inotropic Agents Used for patients with hypotension, end-organ hypoperfusion, or shock secondary
to myocardial pump failure
Vasopressors Considered for cardiogenic shock, despite inotropic support
Disadvantage: may also increase afterload because of the peripheral
vasoconstriction
PHASE 2: HOSPITAL CARE
The goals for the management of a patient with AHF during the hospitalization phase are to
complete the diagnostic and acute therapeutic processes that were initiated at the initial
presentation, optimize the patient's hemodynamic profile, volume status, and clinical
symptoms, and to initiate or optimize chronic HF therapy

PHASE 3: PREDISCHARGE PLANNING

PHASE 4: POSTDISCHARGE MANAGEMENT

•Early recurrence of signs and symptoms of HF suggestive of

worsening volume overload and/or neurohormonal activation are
likely to contribute to the high rates of readmission that are
observed in AHF
•Prompt interventions may therefore prevent the progression of
volume overload and new admissions
HF with REDUCED EJECTION FRACTION
 HF with REDUCED EJECTION FRACTION
STAGE A

• For patients at high risk of developing HFrEF, every effort should be made
to prevent HF, using standard practice guidelines to treat preventable
conditions that are known to lead to HF, including hypertension,
hyperlipidemia, and diabetes
• In this regard, ACEIs are particularly useful in preventing HF in
patients who have a history of atherosclerotic vascular disease, diabetes
mellitus, or hypertension with associated CV risk factors
HFrEF STAGE A FRAMINGHAM CRITERIA AND NHANES CRITERIA
 HFrEF
Drug Class Description

ACE Inhibitors Cornerstone of modern HF treatment

Catopril – 6.25-50 mg TID Enalapril – 2.5 20 mg BID Interferes with RAAS by inhibiting conversion of angiotensin-I to angiotensin II
Inhibits kinase, which increases bradykinin (causes ACE-I induced cough)
ARB (Losartan 50 mg OD) Used if ACEI intolerant (i.e cough, angioedema)

Beta Blockers (BB) Another cornerstone of modern HF therapy

Interferes with sustained activation of the adrenergic nervous system, particularly the
Carvedilol – 3.125-25 mg BID deleterious effects of B1 activation
Bisoprolol 1.25-10 mg OD
Aldosterone Antagonist Inhibits action of aldosterone on the collecting duct
May also be used for fluid retention
Spironolactone 25-50 mg OD
Digoxin 0.125-0.375 mg OD Inhibits Na-K-ATPase pump, increasing intracellular Ca2+ , which leads to increased cardiac
contractility
For symptomatic LV dysfunctionwith concomitant atrial fibrillation • Add-on standard
therapy
Ivabradine 5.0-7.5 mg BID Reduces heart rate by inhibition of the “funny channel” (If ) in the SA node
Primarily used for symptomatic chronic stable angina
May be used on top of BB for HF with systolic dysfunction in patients with sinus rhythm and
heart rate >70 bpm
Angiotensin receptor Neprilysin Inhibitor (ARNI): Combines an ARB and a neprilysin inhibitor
LCZ696 (Sacubitiril + Valsartan) Recommended to replace ACE-inhibitors in ambulatory HFrEF patients who remain
symptomatic despite optimal therapy
DRUG CLASS DESCRIPTION / MECHANISM

Loop Diuretics Act on the loop of Henle by reversibly inhibiting the

reabsorption of Na, K, Cl in the think ascending limb

Thiazide Diuretics Reduce reabsorption of Na and Cl in the 1st half of the distal
convoluted tubule.
Tend to lose their efficacy with moderate/severe renal
insufficiency

Arginine Vasoprin (AVP) Antagonists
Interfere with the action at the vasopressin receptors of the
renal collecting ducts.
Primarily used for treatment of hyponatremia by stimulating
free-water excretion and improving plasma Na+
concentration
CLASS NYHA I NYHA II NYHA III-IV NYHA IBV

ACEI / ARB Yes Yes Yes Yes

Diuretic NO Yes, if with fluid Yes Yes

retention

B-blocker Yes, if post-MI Yes Yes Yes

Aldosterone Yes, if post-MI Yes Yes Yes

antagonist

Digoxin May be considered May be considered Yes Yes

DEVICES USED IN HF:

▪ Cardiac Resynchronization Therapy (CRT) or

Biventricular Pacing:
Device used to restore synchronized
contraction on the left and right ventricles in
patients with HF in sinus rhythm and a widened
QRS complex

▪ Implantable Cardioverter-Defibrillator (ICD):

Device to treat tachyarrhthmias for primary
or secondary prophylaxis against sudden cardiac
death (SCD)
 SURGERY

SURGICAL VENTRICULAR RESTORATION

Technique characterized by infarct exclusion to remodel the left ventricle by reshaping it
surgically in patients with ischemic cardiomyopathy and dominant anterior left ventricular
dysfunction

CORONARY BYPASS GRAFTING

Recognition that hibernating myocardium (myocardial tissue with abnormal function but
with maintained cellular function) could recover after vascularization led to the notion of
revascularization with CABG