Download Current Guidelines For The Evaluation And Management Of Heart

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PAGE 2| Introduction To The
Guidelines: Heart Failure
PAGE 3| Guest Editor Comment
PAGE 4| Assessment Of The
Guideline Methodology
PAGE 5 | Selected Guideline
Recommendations,
With Discussion
PAGE 12| References
PAGE 13| CME Questions
Current Guidelines For The
Evaluation And Management Of
Heart Failure
T
his issue of EM Practice Guidelines Update reviews 2
recently updated guidelines on the evaluation and management of heart failure (HF). The European Society of
Cardiology (ESC) guideline is an update of their 2008 issue and
provides practical, evidence-based guidelines for the diagnosis
and treatment of acute and chronic HF. The joint American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) guideline is an update of their 2009 publication that
is primarily focused on chronic HF. The focus of this review is
on the recommendations most relevant to emergency medicine
practice—the assessment and treatment of acute HF.
Practice Guideline Impact
•
Editor’s Note: To read more about this publication
and the background and methodologies for practice
guideline development, go to:
http://www.ebmedicine.net/introduction
B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurements are useful to support
clinical judgment for the diagnosis of acute HF, especially in the
setting of clinical uncertainty.
January/February 2014
Volume 6, Number 1
Author
Trevor Lewis, MD, FACEP
Medical Director, Emergency Department, Cook County Hospital; Associate
Professor of Emergency Medicine, Rush Medical College, Chicago, IL
Guest Editor
Deborah B. Diercks, MD
Professor and Vice Chair of Research, Department of Emergency Medicine,
University of California, Davis, Davis, CA
Editor-In-Chief
Sigrid Hahn, MD, MPH
Associate Professor of Emergency Medicine, Department of Emergency
Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
Editorial Board
Luke K. Hermann, MD
Associate Professor of Emergency Medicine, Director of Quality and Finance,
Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai,
New York, NY
Andy Jagoda, MD, FACEP
Professor and Chair, Department of Emergency Medicine, Icahn School of
Medicine at Mount Sinai, New York, NY
Eddy S. Lang, MDCM, CCFP (EM), CSPQ
Senior Researcher, Alberta Health Services; Associate Professor, University of
Calgary; Adjunct Professor, McGill University, Montreal, Quebec, Canada
Trevor Lewis, MD, FACEP
Medical Director, Emergency Department, Cook County Hospital; Associate
Professor of Emergency Medicine, Rush Medical College, Chicago, IL
Gregory M. Press, MD, RDMS
Emergency Ultrasound Director, Hutt Valley Hospital, Lower Hutt, New Zealand
Christopher Tainter, MD, RDMS
•
A completely normal electrocardiogram (ECG) indicates that HF
is unlikely.
Critical Care Fellow, Department of Anesthesia, Critical Care, and Pain
Medicine, Massachusetts General Hospital/Harvard Medical School, Boston,
MA
•
Patients with acute HF should be treated promptly with intravenous (IV) diuretics to reduce morbidity.
Chair, Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL
•
•
Vasodilators may be used as an adjunct to diuretic therapy in an
effort to reduce dyspnea, but they do not improve major outcomes.
Drugs that are potentially harmful in patients with a reduced
ejection fraction include most antiarrhythmic drugs, most calcium-channel-blocking drugs (except amlodipine), and nonsteroidal anti-inflammatory drugs (NSAIDs).
Scott M. Silvers, MD
Scott D. Weingart, MD, FCCM
Associate Professor, Department of Emergency Medicine, Director, Division of
ED Critical Care, Icahn School of Medicine at Mount Sinai, New York, NY
Prior to beginning this activity, see “CME Information”
on page 14.
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Current Guidelines For The Evaluation And Management Of Heart Failure
Introduction To The Guidelines: Heart Failure
T
“heart failure with a reduced ejection fraction” (HFrEF), defined as an
EF ≤ 40%.4 The ESC uses similar definitions, but considers a reduced
EF to be ≤ 35%.5 EFs of 35% to 50% encompass a gray area, and
most likely represent patients with mild systolic dysfunction. There is
also no standardized terminology to describe acutely or subacutely
worsened HF, and the terms “acute heart failure,” “acute heart failure
syndromes,” and “acutely decompensated heart failure” have been
used by various authors and organizations. The ACCF/AHA suggests
that the use of clinical descriptors can help subclassify patients with
acute HF as congested or not (“wet” or “dry”) and/or as being wellperfused or not (“warm” or “cold”).
his issue of EM Practice Guidelines Update reviews 2 recently
published guidelines on the evaluation and management of HF:
1. “ESC Guidelines for the Diagnosis and Treatment of Acute and
Chronic Heart Failure 2012,” published by the European Society of
Cardiology (ESC), available at:
http://eurheartj.oxfordjournals.org/content/33/14/1787.full.pdf
2. “2013 ACCF/AHA Guideline for the Management of Heart Failure:
a Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines,” published by the American Heart Association (AHA), available at:
http://circ.ahajournals.org/content/early/2013/06/03/
CIR.0b013e31829e8776.full.pdf
This issue of EM Practice Guidelines Update will inform the emergency
clinician of the new and updated guidelines in the diagnosis and care
of patients with HF. Faced with the pressures of managing patients
with acute HF or HF as a comorbidity, reducing admission rates for
acute HF, and determining the often subtle presentations of new-onset
HF in the ED, the emergency clinician must be well-versed in the acute
treatment guidelines, chronic treatment regimens, and approaches to
diagnosis. Many of the recommendations in the full guidelines apply
to the outpatient setting, and only those that are applicable to the care
of the ED patient will be reviewed here. The ACCF/AHA guidelines are
more focused on the United States population and much broader in
their discussion of outpatient management and chronic congestive HF.
The ESC recommendations apply to a more global population, with a
greater focus on acute care.
HF is a common condition affecting approximately 1% to 2% of the
adult population, with a prevalence of ≥ 10% in patients aged > 70
years.1 Survival for HF patients has improved, but absolute mortality
rates remain at approximately 50% at 5 years for all-cause HF.2 There
is some evidence that the number of hospitalizations attributed primarily to HF is declining; however, there has been an increase in the
number of hospitalizations of patients with a diagnosis of chronic HF.3
HF is a heterogeneous clinical syndrome caused by structural and
functional impairment of ventricular filling or ejection of blood, resulting primarily in dyspnea and fatigue with or without symptoms of
volume overload.4 There is no definitive diagnostic test for HF. As a
result, there is considerable variability in the definitions and terminology used to describe HF. The AHA recommends against use of the
term “congestive heart failure,” as fluid overload need not be present,
and prefers the term “heart failure.” The ACCF/AHA guideline writing committee used the terms “heart failure with a preserved ejection
fraction” (HFpEF), defined as an ejection fraction (EF) ≥ 50%; and
EM Practice Guidelines Update © 2014
—Trevor Lewis, MD
2
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Current Guidelines For The Evaluation And Management Of Heart Failure
Guest Editor Comment: Deborah Diercks, MD
For the emergency clinician, an ideal guideline on HF would provide
clear recommendations for decsions regarding ED-based diagnostics,
treatment, and disposition. These 2 recently published guidelines by
the major American and European cardiology societies focus largely
on the care of chronic HF, but they also provide guidance for patients
presenting with acute HF. The ACCF/AHA HF guideline covers acute
care under the section entitled “The Hospitalized Patient." It does not
explicitly address the ED setting (not surprising, perhaps, as no emergency physicians were included on the writing panel).
a randomized controlled trial (RCT) from 2008 did not show positive
results;6 however, readers should be reminded of the 2013 Cochrane
review (which included this RCT) that showed a reduction in mortality, a reduction in the need for endotracheal intubation, as well as a
reduction in the number of days spent in the intensive care unit without
increasing the risk of having a heart attack during or after treatment.7
Overall, the treatment guidelines are relatively consistent with current
practices in the ED, so they may provide reassurance to ED clinicians
that their current management plan is sufficient. However, these guidelines also highlight important regulatory benchmarks that are tracked
on HF patients, and these are relevant, as emergency clinicians are
taking a more comprehensive role in the management of acute HF
patients. The outcome measures of admission rates and 30-day riskstandardized HF readmission rates are clearly in the domain of the
emergency clinician. Currently, there are approximately 700,000 ED
visits for acute HF per year in the United States, approximately 80%
of which result in admission.8 Despite this (and perhaps because the
ACCF/AHA writing committee did not focus on the ED setting), the
question of risk stratification and potential discharge from the ED is not
addressed.
The ACCF/AHA continues to suggest categorization of acute HF patients by their hemodynamic status and degree of congestion. Diagnostic tests (eg, chest x-ray and natriuretic peptide levels) can be used
to assist in this assessment. For patients with congestion who are
hemodynamically stable, the Class I recommendation is to use loop
diuretics as part of the initial management (“...to be given in the ED”).
Adjuncts to diuretics that are also suggested (with Class IIb recommendations) include low-dose dopamine, ultrafiltration, IV vasodilators (nitroglycerin, nitroprusside, nesiritide), and vasopressin receptor
antagonists (for patients with severe hyponatremia). Ultrafiltration may
not be relevant to emergency clinicians outside of specialized healthcare settings, as it requires resources that are limited in the ED setting.
Surprisingly, the ACCF/AHA guidelines do not address the use of noninvasive ventilation (NIV). Unlike ultrafiltration, NIV is widely available
and in common use in the ED.
The recommendations in the ACCF/AHA guidelines for management of
acute HF are somewhat difficult to locate within the document; however, the ESC guidelines present the information in a clear format. The
best use of the ACCF/AHA guidelines is as a reference for specific issues. For the emergency clinician seeking to practice guideline-based
therapy and utilize algorithms, the ESC guidelines are much more
useful. ■
In contrast to the ACCF/AHA guidelines, the ESC HF guidelines present more comprehensive and user-friendly recommendations for
patients presenting with acute HF. These guidelines present algorithms
for diagnosis and management, and, unlike the ACCF/AHA guidelines
that suggest treatment based on assessment of perfusion and congestion, these guidelines recommend treatment based on blood pressure
and oxygenation in patients with pulmonary congestion. The actual
treatment recommendations differ very little between the guidelines.
The ESC does address NIV, endorsing it with a IIB recommendation
based on class B evidence. In their discussion, they cite concern that
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Current Guidelines For The Evaluation And Management Of Heart Failure
Assessment Of The Guideline Methodology
A
committee appointed by the ACCF/AHA Task Force on Practice
Guidelines authored the ACCF/AHA guidelines. The definitions and levels of recommendations are noted in Table 1. Members
of the ESC Task Force were selected by the ESC to write the guideline in accordance with the ESC Committee for Guidelines Policy. The
same definitions for the recommendations were utilized as noted in
Table 1.
Table 1. Definition Of Classes And Levels Of Evidence Used In American
Heart Association Recommendations
Level of Evidence
A
Data derived from multiple sources
B
Data derived from a single randomized trial or nonrandomized studies
C
Consensus opinion of experts
Classes of Recommendation
The authors of this issue of EM Practice Guidlines Update, Trevor
Lewis, MD and Editor-in-Chief Sigrid Hahn, MD, MPH graded this
guideline using the Appraisal of Guidelines for Research and Education (AGREE) II instrument (available at http://www.agreetrust.org/).
This instrument is a checklist that allows users to grade a guideline on
23 items in 6 domains, reflecting the degree to which the guideline developers used unbiased, best-practice methodology in developing the
guideline and writing the recommendations. The results of the AGREE
instrument are presented in Figure 1, with a percentile calculated and
assigned for each domain (maximum score of 100%). The score for
relevance to emergency medicine is not part of the AGREE instrument,
but reflects the judgment of the author and editor of this issue
Class I
Conditions for which there is conflicting evidence for and/or general
agreement that the procedure or treatment is useful and effective
Class II
Conditions for which there is conflicting evidence and/or a divergence of
opinion about the usefulness/efficacy of a procedure or treatment
Class IIa
The weight of evidence or opinion is in favor of the procedure or treatment
Class IIb
Usefulness/efficacy is less well established by evidence or opinion
Class III
Conditions for which there is evidence and/or general agreement that
the procedure or treatment is not useful/effective and in some cases
may be harmful
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Figure 1. AGREE Criteria For Heart Failure Guidelines
Scope and purpose
—Trevor Lewis, MD; and Sigrid Hahn, MD, MPH
Stakeholder involvement
Rigor of development
n ESC
Clarity of presentation
n ACCF/AHA
Applicability
Editorial independence
Overall guideline quality
Relevance to emergency medicine
0
Abbreviation: AGREE, Appraisal of
EM Practice Guidelines Update © 2014
4
20
40
60
Percentile
Score
Guidelines for Research and
80
100
Education.
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Current Guidelines For The Evaluation And Management Of Heart Failure
Selected Guideline Recommendations, With Discussion
T
he recommendations excerpted here are presented as they appear in the original guidelines, including the strength of the
recommendation and the level of evidence. Recommendations
on the same clinical topic from the 2 guidelines are presented sideby-side to facilitate comparison. However, when there is overlap and
no significant discrepancy, only 1 of the 2 guideline recommendations
are presented, in the interest of brevity. Disease prevention, nonsurgical device implantation, and surgical options are not reviewed, as they
have limited relevance to the emergency clinician.
markers, including cardiac troponin testing, and treated optimally
as appropriate to the overall condition and prognosis of the patient.
(ACCF/AHA, Class I, Level C)
Electrocardiogram
• A 12-lead ECG is recommended to determine heart rhythm, heart
rate, QRS morphology, and QRS duration, and to detect other
relevant abnormalities. This information also assists in planning
treatment and is of prognostic importance. A completely normal
ECG makes systolic HF unlikely. (ESC, Class I, Level C)
Initial Assessment Of Suspected Acute Heart Failure
• Common precipitating factors for acute HF should be considered
during initial evaluation, as recognition of these conditions is critical
to guide appropriate therapy. (ACCF/AHA, Class I, Level C)
• Common factors that precipitate acute decompensated HF include:
◦◦ Nonadherence with medication regimen, sodium and/or fluid
restriction
◦◦ Acute myocardial ischemia
◦◦ Uncorrected high blood pressure
◦◦ Atrial fibrillation and other arrhythmias
◦◦ Recent addition of negative inotropic drugs (eg, verapamil, nifedipine, diltiazem, beta blockers)
◦◦ Pulmonary embolus
◦◦ Initiation of drugs that increase salt retention (eg, steroids, thiazolidinediones, NSAIDs)
◦◦ Excessive alcohol or illicit drug use
◦◦ Endocrine abnormalities (eg, diabetes mellitus, hyperthyroidism, hypothyroidism)
◦◦ Concurrent infections (eg, pneumonia, viral illnesses)
◦◦ Additional acute cardiovascular disorders (eg, valve disease
endocarditis, myopericarditis, aortic dissection)
• Acute coronary syndromes (ACS) precipitating acute HF decompensation should be promptly identified by ECG and serum bio-
EM Practice Guidelines Update © 2014
Chest X-Ray
• Patients with suspected or new-onset HF or patients presenting
with acute decompensated HF, should undergo a chest x-ray to assess heart size and pulmonary congestion and to detect alternative
cardiac, pulmonary, and other diseases that may cause or contribute to the patient’s symptoms. (ACCF/AHA, Class I, Level C)
Editorial Comment: Trevor Lewis, MD
Several points are worth highlighting: (1) Heart failure is very unlikely
in patients with a normal ECG; (2) A normal chest x-ray does not
exclude pulmonary edema and is better for identifying an alternative diagnosis than for ruling in acute HF; (3) Although ESC does not make a
formal recommendation about the role of echocardiography in the ED
(the recommendations about echocardiography refer to the ambulatory
setting), they incorporate echocardiography in their diagnostic algorithm for acute HF. They endorse early echocardiography for patients
presenting to the ED with suspected acute HF (immediate echocardiography is recommended in shocked or severely hemodynamically
compromised patients). Neither organization discusses the role of
bedside echocardiography. (See Figure 2, page 6.)
5
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Current Guidelines For The Evaluation And Management Of Heart Failure
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Figure 2. European Society Of Cardiology Recommended Diagnostic Testing For Acute Heart Failure
Suspected heart failure of acute onset
• ECG
• Chest x-ray
• BNP/NT-proBNP*
ECG abnormal
or
NT-proBNP ≥ 300 pg/mL†
or
BNP ≥ 100 pg/mL†
ECG normal
and
NT-proBNP < 300 pg/mL
or
BNP < 100 pg/mL
Echocardiogram
Heart failure unlikely‡
If heart failure is confirmed, determine
etiology and start appropriate treatment
*In the acute setting, MR-proANP may also be used (cut-off point < 120 pmol/L; ie, < 120 pmol/L = heart failure unlikely).
†
Other causes of elevated natriuretic peptide levels in the acute setting are an acute coronary syndromes, atrial or ventricular arrhythmias, pulmonary embolism, and severe chronic obstructive pulmonary disease with
elevated right heart pressure, renal failure, and sepsis. Other causes of an elevated natriuretic level in the nonacute setting are: old age (> 75 years), atrial arrhythmias, left ventricular hypertrophy, chronic obstructive
pulmonary disease, and chronic kidney disease.
‡
Treatment may reduce natriuretic peptide concentration, and natriuretic concentrations may not be markedly elevated in patients with HF-PEF.
Abbreviations: BNP, B-type natriuretic peptide; ECG, electrocardiogram; HF-pEF, heart failure with preserved ejection fraction; MR-proANP, midregional pro-atrial natriuretic peptide; NT-proBNP, N-terminal B-type
natriuretic peptide.
EM Practice
Practice Guidelines
Guidelines Update
Update ©
© 2011
2014
EM
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ebmedicine.net
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Current Guidelines For The Evaluation And Management Of Heart Failure
Treatment Of Acute Heart Failure Without Shock
Oxygen
High-flow oxygen is recommended in patients with a capillary oxygen
saturation < 90% or PaO2 < 60 mm Hg (8.0 kPa) to correct hypoxemia.
(ESC, Class I, Level C)
Laboratory Testing
• Measurement of BNP or NT-proBNP is useful to support clinical
judgment for the diagnosis of acutely decompensated HF, especially in the setting of uncertainty for the diagnosis. (ACCF/AHA, Class
I, Level A; revised from previous guidelines)9
• Measurement of BNP or NT-proBNP and/or cardiac troponin is
useful for establishing prognosis or disease severity in acutely
decompensated HF. (ACCF/AHA, Class I, Level A; revised from
previous guidelines)9
• The usefulness of BNP- or NT-proBNP-guided therapy for acutely
decompensated HF is not well established. (ACCF/AHA, Class IIb,
Level C, new recommendation)
• Measurement of other clinically available tests (such as biomarkers
of myocardial injury or fibrosis) may be considered for additive risk
stratification in patients with acutely decompensated HF. (ACCF/
AHA, Class IIb, Level A, new recommendation)
• Measurement of natriuretic peptide (BNP, NT-proBNP, or midregional
pro-atrial natriuretic peptide [MR-proANP]) should be considered to:
◦◦ Exclude alternative causes of dyspnea (if the level is below the
exclusion cut-point, HF is very unlikely) (ESC, Class IIb, Level C)
◦◦ Obtain prognostic information (ESC, Class IIb, Level C)
Editorial Comment: Trevor Lewis, MD
Oxygen should not be used routinely in nonhypoxic patients as it
causes vasoconstriction and reduced cardiac output.
Noninvasive Ventilation
NIV (eg, CPAP) should be considered in dyspneic patients with pulmonary edema and a respiratory rate > 20 breaths/min to improve breathlessness and reduce hypercapnia and acidosis. NIV can reduce blood
pressure and should not generally be used in patients with a systolic
blood pressure (SBP) < 85 mm Hg (and blood pressure should be monitored regularly when this treatment is used). (ESC, Class IIa, Level B)
Editorial Comment: Trevor Lewis, MD
The use of NIV has become routine in the management of patients
presenting to the ED with acute HF. As previously noted, a 2013 Cochrane meta-analysis found a reduction in hospital mortality and the
need for intubation with NIV.7 The ESC guideline authors, however, cite
an RCT (also included in the meta-analysis) that demonstrated that
neither continuous positive airway pressure (CPAP) nor noninvasive
positive pressure ventilation (NIPPV) reduced mortality or the rate of
endotracheal intubation when compared with standard therapy.6 This
appears to be why they describe NIV as an “adjunct” therapy for patients who are not improving with pharmacologic therapy or who are in
severe distress, rather than as a Class I, first-line therapy.
Editorial Comment: Trevor Lewis, MD
Routine laboratory testing can help elucidate possible causes of acute
HF (such as anemia). The ACCF/AHA guideline newly recommends
measuring troponin for “additive risk stratification” in acute HF, and comments that the measurement of troponins should be routine in patients
presenting with acute HF. The ESC suggests only that troponins “may
be indicated” in the ED patient. The ACCF/AHA has revised its recommendations regarding the use of BNP and provides a strong recommendation in support of the role of BNP in cases of diagnostic uncertainty
(much stronger than the ESC). The ESC guideline emphasizes the ability of a BNP measurement to exclude acute HF in the ED patient if NTproBNP is < 300 pg/mL or BNP is < 100 pg/mL. BNP also has obvious
prognostic value, but no established value in guiding treatment. The role
of BNP in the diagnostic workup of acute HF is shown in the algorithm
from the ESC guideline. (See Figure 2, page 6.)
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Current Guidelines For The Evaluation And Management Of Heart Failure
Treatment Of Acute Heart Failure Without Shock (Continued)
Diuretics
• Patients with HF admitted with evidence of significant fluid overload
should be promptly treated with IV loop diuretics to reduce morbidity. (ACCF/AHA, Class I, Level B)
• If patients are already receiving loop diuretic therapy, the initial
IV dose should equal or exceed their chronic oral daily dose and
should be given as either intermittent boluses or as a continuous infusion. Urine output and signs and symptoms of congestion should be serially assessed, and the diuretic dose should be
adjusted accordingly to relieve symptoms, reduce volume excess,
and avoid hypotension. (ACCF/AHA, Class I, Level B; revised from
previous guideline)9
• An IV loop diuretic is recommended to improve breathlessness and
relieve congestion. Symptoms, urine output, renal function, and
electrolytes should be monitored regularly during use of IV diuretics
(ESC, Class I, Level B)
• Low-dose dopamine infusion may be considered in addition to loop
diuretic therapy to improve diuresis and to better preserve renal
function and renal blood flow. (ACCF/AHA, Class IIb, Level B)
Vasodilators
• If symptomatic hypotension is absent, IV nitroglycerin, nitroprusside, or nesiritide may be considered an adjuvant to diuretic therapy for relief of dyspnea in patients admitted with acutely decompensated HF. (ACCF/AHA, Class IIb, Level B)
• An IV infusion of a nitrate should be considered in patients with
pulmonary congestion/edema and a SBP > 110 mm Hg who do not
have severe mitral or aortic stenosis, to reduce pulmonary capillary
wedge pressure and systemic vascular resistance. Nitrates may
also relieve dyspnea and congestion. Symptoms and blood pressure should be monitored frequently during administration of IV
nitrates. (ESC, Class IIa, Level B)
• An IV infusion of sodium nitroprusside may be considered in
patients with pulmonary congestion/edema and a SBP > 110 mm
Hg who do not have severe mitral or aortic stenosis, to reduce
pulmonary capillary wedge pressure and systemic vascular resistance. Caution is recommended in patients with acute myocardial
infarction. Nitroprusside may also relieve dyspnea and congestion.
Symptoms and blood pressure should be monitored frequently during administration of IV nitroprusside. (ESC, Class IIa, Level B)
Editorial Comment: Trevor Lewis, MD
Both guidelines conclude that diuretics are a cornerstone of therapy for
acute HF. The AHA guidelines codify what has already been a common
ED dosing regimen for years, and they recommend starting diuretics
in the ED without delay, in an effort to improve outcomes (although
their impact on mortality is not well established). The ESC guideline
does not specify dosing, noting the lack of good evidence for the use
of high-dose over low-dose loop diuretics and tradeoffs that include
transiently worsened renal function. The addition of a thiazide diuretic
is a good option to remember when initial aggressive furosemide dosing is inadequate. The weak recommendation to consider dopamine is
added in this section for reader interest; however, it should be noted
that this is based on a single study and the guideline authors remarked
that more data are needed.
Editorial Comment: Trevor Lewis, MD
Both guideline writing committees conclude that, overall, there are no
data to suggest that IV vasodilators improve major outcomes in the
patient hospitalized with HF. IV vasodilators may help relieve dyspnea.
The ACCF/AHA guideline also cautions that IV vasodilators should be
administered with caution in patients with HFpEF, as these patients are
typically more volume sensitive.
EM Practice Guidelines Update © 2014
Opiates
An IV opiate (along with an antiemetic) should be considered in particularly anxious, restless, or distressed patients to relieve these
symptoms and improve breathlessness. Alertness and ventilatory effort
should be monitored frequently after administration because opiates
can depress respiration. (ESC, Class IIa, Level C)
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Current Guidelines For The Evaluation And Management Of Heart Failure
Treatment Of Acute Heart Failure Without Shock (Continued)
Inotropes And Vasopressors
• Inotropic agents are NOT recommended unless the patient is hypotensive (SBP < 85 mm Hg), hypoperfused, or shocked because
of safety concerns (atrial and ventricular arrhythmias, myocardial
ischemia, and death). (ESC, Class III, Level C)
• Use of parenteral inotropic agents in hospitalized patients without
documented severe systolic dysfunction, low blood pressure, or
impaired perfusion and evidence of significantly depressed cardiac
output, with or without congestion, is potentially harmful. (ACCF/
AHA, Class III, Level B)
•
•
Editorial Comment: Trevor Lewis, MD
Inotropes or vasopressors are only potentially appropriate in patients
with significant hypoperfusion or cardiogenic shock. (See discussion
following.)
•
Treatment Of Acute Heart Failure With Hypotension,
Hypoperfusion, Or Shock
Cardioversion
• Electrical cardioversion is recommended if an atrial or ventricular
arrhythmia is thought to be contributing to the patient’s hemodynamic compromise in order to restore sinus rhythm and improve
the patient’s clinical condition. (ESC, Class I, Level C)
Editorial Comment: Trevor Lewis, MD
Patients with acute HF and shock have severely compromised circulatory status, and the use of inotropes and vasopressors requires
an assessment of the tradeoff between potential benefits and risks
(including myocardial ischemia and arrhythmias) in these critically ill
patients. Despite improving hemodynamic status, inotropes have not
been shown to improve patient outcomes. Of note, many of the studies
focus on end-stage chronic HF patients, which may not be applicable
to the acute presentation of the ED patient.
Inotropes And Vasopressors
• Short-term, continuous IV inotropic support may be reasonable in
hospitalized
patients presenting with documented severe systolic
dysfunction who present with low blood pressure and significantly
depressed cardiac output to maintain systemic perfusion and
preserve end-organ performance (ACCF/AHA, Class IIb, Level B;
revised from previous guideline)9
• Until definitive therapy (eg, coronary revascularization, mechanical circulatory support, heart transplantation) or resolution of the
acute precipitating problem, patients with cardiogenic shock should
receive temporary IV inotropic support to maintain systemic perfusion and preserve end-organ performance. (ACCF/AHA, Class I,
Level C)
EM Practice Guidelines Update © 2014
An IV infusion of an inotrope (eg, dobutamine) should be considered in patients with hypotension (SBP < 85 mm Hg) and/or hypoperfusion to increase cardiac output, increase blood pressure,
and improve peripheral perfusion. The ECG should be monitored
continuously because inotropic agents can cause arrhythmias and
myocardial ischemia. (ESC, Class IIa, Level C)
A vasopressor (eg, dopamine or norepinephrine) may be considered in patients who have cardiogenic shock, despite treatment
with an inotrope, to increase blood pressure and vital organ perfusion. The ECG should be monitored, as these agents can cause
arrhythmias and/or myocardial ischemia. Intra-arterial blood pressure measurement should be considered. (ESC, Class IIb, Level C)
An IV infusion of levosimendan (or a phosphodiesterase inhibitor)
may be considered to reverse the effect of beta blockade if beta
blockade is thought to be contributing to hypoperfusion. The ECG
should be monitored continuously because inotropic agents can
cause arrhythmias and myocardial ischemia, and, as these agents
are also vasodilators, blood pressure should be monitored carefully. (ESC, Class IIb, Level C)
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Current Guidelines For The Evaluation And Management Of Heart Failure
ST-segment elevated myocardial infarction (NSTEMI) is complicated
by the fact that patients both with and without coronary artery disease
often have elevated troponin levels in the setting of acute HF.
Treatment Of Acute Heart Failure With Hypotension,
Hypoperfusion, Or Shock (Continued)
Mechanical Circulatory Support
• Short-term mechanical circulatory support should be considered
(as a “bridge to recovery”) in patients remaining severely hypoperfused despite inotropic therapy and with a potentially reversible
cause (eg viral myocarditis) or a potentially surgically correctable
cause (eg acute interventricular septal rupture). (ESC, Class IIa,
Level C)
• Short-term mechanical circulatory support may be considered (as
a ‘bridge to decision’) in patients deteriorating rapidly before a full
diagnostic and clinical evaluation can be made. (ESC, Class IIb,
Level C)
Treatment Of Acute Heart Failure With An Arrhythmia
• Electrical cardioversion is recommended in patients hemodynamically compromised by atrial fibrillation and in whom urgent restoration of sinus rhythm is required to improve the patient’s clinical
condition rapidly. (ESC, Class I, Level C)
• Patients should be fully anticoagulated (eg, with IV heparin), if not
already anticoagulated and with no contraindication to anticoagulation, as soon as atrial fibrillation is detected to reduce the risk of
systemic arterial embolism and stroke. (ESC, Class I, Level A)
• Electrical cardioversion or pharmacological cardioversion with
amiodarone should be considered in patients when a decision is
made to restore sinus rhythm nonurgently (“rhythm control” strategy). This strategy should only be employed in patients with a first
episode of atrial fibrillation of < 48 hours’ duration (or in patients
with no evidence of left atrial appendage thrombus on transesophageal echocardiogram). (ESC, Class I, Level C)
Treatment Of Acute Heart Failure Due To Acute Coronary
Syndromes
• Immediate primary percutaneous coronary intervention (PCI) (or
coronary artery bypass graft [CABG] in selected cases) is recommended if there is an ST elevation or a new left bundle branch
block ACS in order to reduce the extent of myocyte necrosis and
reduce the risk of premature death. (ESC, Class I, Level A; revised
from previous guideline)10
• Alternative to PCI or CABG: IV thrombolytic therapy is recommended if PCI/CABG cannot be performed, or if there is ST-segment
elevation or new left bundle branch block, to reduce the extent of
myocyte necrosis and reduce the risk of premature death. (ESC,
Class I, Level A; revised from previous guideline)10
• Early PCI (or CABG in selected patients) is recommended if there
is non-ST elevation ACS in order to reduce the risk of recurrent
ACS. Urgent revascularization is recommended if the patient is
hemodynamically unstable. (ESC, Class I, Level A; revised from
previous guideline)10
Editorial Comment: Trevor Lewis, MD
The ACCF/AHA guideline defers to the 2011 ACCF/AHA/HRS Focused
Update on the Management of Patients With Atrial Fibrillation guideline (available at http://circ.ahajournals.org/content/123/1/104.extract)
for treatment of patients with HF and arrhythmia. The ESC guideline
comments on the use of urgent heparin for patients who are not currently anticoagulated. In addition, the guidelines mirror the current
Advanced Cardiac Life Support (ACLS) recommendations to cardiovert the unstable patient. Care must be employed in interpreting what
constitutes an "unstable" patient, especially in the setting of unknown
duration of AF with the potential for atrial clot. A fully revised atrial
fibrillation guideline, which will include updated recommendations on
HF with atrial fibrillation, is in development by the ACCF/AHA, with
publication expected in 2014.
Editorial Comment: Trevor Lewis, MD
Management of patients with ST-segment elevated myocardial infarction
(STEMI) and HF is straightforward, as these patients need immediate
cardiac intervention. In contrast, the diagnosis and management of non-
EM Practice Guidelines Update © 2014
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Current Guidelines For The Evaluation And Management Of Heart Failure
Treatments That May Cause Harm
• Drugs known to adversely affect the clinical status of patients with
current or prior symptoms of HFrEF are potentially harmful and
should be avoided or withdrawn whenever possible (eg, most
antiarrhythmic drugs, most calcium-channel-blocking drugs [except
amlodipine], NSAIDs, or thiazolidinediones). (ACCF/AHA, Class III,
Level B)
• Thiazolidinediones (glitazones) should not be used, as they cause
worsening HF and increase the risk of HF hospitalization. (ESC,
Class III, Level A)
• Most calcium-channel blockers (with the exception of amlodipine
and felodipine) should not be used, as they have a negative inotropic effect and can cause worsening HF. (ESC, Class III, Level B)
• NSAIDs and cyclooxygenase-2 (COX-2) inhibitors should be
avoided, if possible, as they may cause sodium and water retention, worsening renal function, and worsening HF. (ESC, Class III,
Level B)
Summary Of Guideline-Directed Medical Therapy For The
Emergency Physician: Trevor White, MD
The ACCF/AHA guideline emphasizes the importance of “guideline-directed medical therapy," and both they and the ESC spend much time
discussing the appropriate outpatient regimen for the management of
chronic HF. An understanding of these medications is useful for the
emergency clinician when managing HF patients in the ED, whether
they have an acute decompensation or not.
Both angiotensin-converting enzyme (ACE) inhibitors and beta blockers have been cornerstones of HFrEF treatment for years. Key trials
have included the Cooperative North Scandinavian Enalapril Survival
Study (CONSENSUS) and Studies of Left Ventricular Dysfunction
(SOLVD), which have shown reductions in mortality of 27% and 16%,
respectively, with the use of these drugs.11-13 The primary role of angiotensin-receptor blockers (ARBs) still appears to be as a substitute for
patients who are intolerant to ACE inhibitors. The expansion of the role
of mineralocorticoid/aldosterone-receptor antagonists has come from
recent RCTs, including the Eplerenone in Mild Patients Hospitalization
and Survival Study in Heart Failure (EMPHASIS-HF), which found that
patients already taking ACE inhibitors and beta blockers had a decrease in hospitalizations and death.14,15 The bottom line is that the use
of ACE inhibitors, beta blockers, and mineralocorticoid/aldosterone-receptor antagonists is fundamentally important in improving the course
of systolic HF and should, at least, be considered in every patient. The
utility of digoxin still remains more of an additive medication after the
implementation of other first-line therapies. ■
Editorial Comment: Trevor Lewis, MD
These recommendations are new in the current guidelines. They provide a useful summary of drugs for emergency clinicians to avoid when
managing HF. Reviewing a patient’s medication list can provide clues
to reasons for their decompensation. Commonly prescribed diabetes
medications, such as pioglitazone (Actos®) and rosiglitazone (Avandia®) should be avoided in HF patients. More important for emergency
medicine practice is the avoidance of NSAIDs and COX-2 selective
inhibitor medications in HF. These are commonly prescribed medications in the ED and often given to this subset of patients.
EM Practice Guidelines Update © 2014
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Current Guidelines For The Evaluation And Management Of Heart Failure
References
1. Mosterd A, Hoes AW. Clinical epidemiology of heart failure. Heart.
2007;93(9):1137-1146. (Review)
9. Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults: a report of the American College
of Cardiology Foundation/American Heart Association Task Force
on Practice Guidelines developed in collaboration with the International Society for Heart and Lung Transplantation. J Am Coll Cardiol.
2009;53(15):e1-e90. (Guidelines)
2. Roger VL, Weston SA, Redfield MM, et al. Trends in heart failure
incidence and survival in a community-based population. JAMA.
2004;292(3):344-350. (Population-based cohort study; 4537 patients)
10.Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC guidelines for
the diagnosis and treatment of acute and chronic heart failure 2008:
the Task Force for the Diagnosis and Treatment of Acute and Chronic
Heart Failure 2008 of the European Society of Cardiology. Developed
in collaboration with the Heart Failure Association of the ESC (HFA)
and endorsed by the European Society of Intensive Care Medicine
(ESICM). Eur J Heart Fail. 2008;10(10):933-989. (Guidelines)
3. Blecker S, Paul M, Taksler G, et al. Heart failure-associated hospitalizations in the United States. J Am Coll Cardiol. 2013;61(12):12591267. (Nationwide inpatient sample)
4. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for
the management of heart failure: a report of the American College of
Cardiology Foundation/American Heart Association Task Force on
Practice Guidelines. Circulation. 2013;128(16):e240-e319. (Guidelines)
11. Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study
(CONSENSUS). The CONSENSUS Trial Study Group. N Engl J Med.
1987;316(23):1429-1435. (Randomized double-blind study; 253
patients)
5. McMurray JJ, Adamopoulos S, Anker SD, et al. ESC guidelines for
the diagnosis and treatment of acute and chronic heart failure 2012:
The Task Force for the Diagnosis and Treatment of Acute and Chronic
Heart Failure 2012 of the European Society of Cardiology. Developed
in collaboration with the Heart Failure Association (HFA) of the ESC.
Eur J Heart Fail. 2012;14(8):803-869. (Guidelines)
12.Effect of enalapril on mortality and the development of heart failure in
asymptomatic patients with reduced left ventricular ejection fractions.
The SOLVD Investigators. N Engl J Med. 1992;327(10):685-691.
(Randomized double-blind trial; 4228 patients)
6. Gray A, Goodacre S, Newby DE, et al. Noninvasive ventilation in
acute cardiogenic pulmonary edema. N Engl J Med. 2008;359(2):142151. (Multicenter open prospective randomized controlled trial;
1069 patients)
13.Effect of enalapril on survival in patients with reduced left ventricular
ejection fractions and congestive heart failure. The SOLVD Investigators. N Engl J Med. 1991;325(5):293-302. (Randomized doubleblind trial; 2569 patients)
7. Vital FM, Ladeira MT, Atallah AN. Non-invasive positive pressure
ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema. Cochrane Database Syst Rev. 2013;5:CD005351. (Systematic
review; 32 blinded or unblinded randomized or quasi-randomised
studies; 2916 participants)
14.Zannad F, McMurray JJ, Krum H, et al. Eplerenone in patients
with systolic heart failure and mild symptoms. N Engl J Med.
2011;364(1):11-21. (Randomized double-blind trial; 2737 patients)
15.Pitt B, Remme W, Zannad F, et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med. 2003;348(14):1309-1321. (Randomized
trial; 6632 patients)
8. Collins SP, Storrow AB. Moving toward comprehensive acute heart
failure risk assessment in the emergency department: the importance of self-care and shared decision making. JACC Heart Fail.
2013;1(4):273-280. (Assessment)
EM Practice Guidelines Update © 2014
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Current Guidelines For The Evaluation And Management Of Heart Failure
CME Questions
To take the CME test, visit: www.ebmedicine.net/G0114 or scan the QR code below with a smartphone:
1. BNP may be helpful for all of the following clinical scenarios except to:
a.
b.
c.
d.
Support a clinical diagnosis in the setting of suspected acute HF
Provide prognostic information in patients with acute HF
Guide therapy for patients with acute HF
Establish disease severity in patients with acute HF
2. The ACCF/AHA guideline gives the strongest recommendation to which of the following treatments for acute HF?
a.
b.
c.
d.
IV vasodilators
IV diuretics
NIV
IV opiates
3. Which of the following treatment options is generally contraindicated in the severely hypotensive patient with acute HF?
a.
b.
c.
d.
NIV
Inotropes
Vasopressors
Mechanical circulatory support
4. Which of the following classes of medications is generally contraindicated in patients with HFrEF?
a. ACE inhibitors
b. Beta blockers
c.MRAs
d. NSAIDs
EM Practice Guidelines Update © 2014
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Current Guidelines For The Evaluation And Management Of Heart Failure
CME information for EM Practice Guidelines Update
To take the CME test, visit: www.ebmedicine.net/G0114
To contact the Editor-In-Chief, email Sigrid Hahn, MD, MPH at:
[email protected]
Date of Original Release: January 1, 2014. Date of most recent review: December 15, 2013. Termination
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Goals: Upon completion of this article, you should be able to: (1) demonstrate medical decision-making
based on the strongest clinical evidence, (2) cost-effectively diagnose and treat the most critical ED presentations, and (3) describe the most common medicolegal pitfalls for each topic covered.
Objectives: Upon completion of this article, you should be able to: (1) cite recommendations for the evaluation of the patient with suspected acute HF in the ED; (2) describe recommendations for the treatment of the
patient with suspected acute HF in the ED; (3) name medications that are contraindicated in patients with
acute HF; and (4) name medications used for the outpatient management of chronic HF.
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Current
Guidelines
For The
Evaluation
And in
Management
Of Heart Failure
Benign
Benign
Paroxysmal
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A chief-complaint focus: Every issue starts with a patient complaint — just like your daily practice. You’re guided step-by-step
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in reaching the diagnosis — often the most challenging part of your job.
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An evidence-based medicine approach: The degree of acceptance and scientific validity of each recommendation is assessed
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