01Approach to the Critical Patient/attcp67

Immediate priorities

›Airway and ventilation assessment

›Respiratory distress signs

›RR > 30 per minute

›SpO2 < 90% on room air

›Acute pulmonary edema pattern

›Flash pulmonary edema

›BiPAP or CPAP initiation for respiratory distress

›If airway unprotectable or respiratory fatigue, proceed to intubation

›Rapid sequence intubation preparation

›Class I recommendation for intubation when indicated

›Hemodynamic profiling

›Warm-wet profile

›SBP elevated, perfusion intact

›Primary decongestion strategy

›Cold-wet profile

›Low output with congestion

›Inotrope plus diuretic strategy

›Cold-dry profile

›Cardiogenic shock without congestion

›Volume assessment before diuresis

›Cardiogenic shock criteria

›SBP < 90 mmHg or MAP < 65 mmHg

›Signs of hypoperfusion: cool extremities, altered mentation, oliguria

›Lactate >= 2 mmol/l

›Immediate escalation triggers

›Hemodynamically significant arrhythmia

›Rapid atrial fibrillation with hemodynamic compromise

02History/hx77

Cardinal symptoms

›Dyspnea

›Exertional dyspnea

›NYHA functional class I to IV

›Change from baseline functional status

›Orthopnea

›Number of pillows required

›New or worsened orthopnea

›Paroxysmal nocturnal dyspnea

›Nocturnal awakening with breathlessness

›Bendopnea

›Dyspnea when bending forward

›Elevated filling pressure marker

›Fluid overload symptoms

›Lower extremity swelling

›Bilateral vs unilateral

›Rate of progression

›Weight gain

›Daily weight monitoring history

›> 2 lbs in 24 hours or > 5 lbs in one week

›Abdominal bloating and early satiety

›Ascites concern

›Hepatic congestion

Precipitant identification

›Dietary and medication triggers

›Dietary sodium indiscretion

›High-sodium meal history

›Fluid intake excess

03Physical Exam/exam57

Vital signs

›Hemodynamic snapshot

›Blood pressure

›Hypertensive acute HF (SBP > 140 mmHg)

›Hypotension (SBP < 90 mmHg) as cardiogenic shock marker

›Narrow pulse pressure (< 25% of SBP) as low output marker

›Heart rate

›Tachycardia > 100 suggesting decompensation or arrhythmia

›Rapid irregular rhythm suggesting atrial fibrillation

›Respiratory rate

›>= 30 per minute as severity marker

›Oxygen saturation

›Room air value

›Ambulatory desaturation assessment

Cardiovascular exam

›Jugular venous pressure

›Most reliable sign of elevated filling pressures

›JVP > 8 cmH2O elevated

›Hepatojugular reflux assessment

›Kussmaul sign if present

›Constrictive pericarditis or RV failure consideration

›Cardiac auscultation

›S3 gallop

›Volume overload marker

›Reduced LV compliance

›S4 gallop

›Diastolic dysfunction marker

›Murmurs

04Differential Diagnosis/ddx46

Life-threatening mimics

›Immediate threats to exclude

›Acute coronary syndrome

›ICD-10 I21 (STEMI), I22 (subsequent MI)

›ECG and troponin evaluation

›Pulmonary embolism

›ICD-10 I26

›Acute dyspnea, pleuritic pain, tachycardia, hypoxia

›CT pulmonary angiography to differentiate

›Cardiac tamponade

›ICD-10 I31.4

›Beck's triad, pulsus paradoxus, electrical alternans

›Pericardial effusion on POCUS

›Cardiogenic shock causes

›Acute valvular dysfunction

›Mitral regurgitation from papillary muscle rupture

›Aortic stenosis decompensation

›Right ventricular failure

›Massive PE trigger

›Inferior STEMI with RV infarct

Common mimics

›Pulmonary causes

›COPD exacerbation

›ICD-10 J44.1

›Hypercapnia, minimal infiltrate

›BNP helps differentiate

›Pneumonia

›ICD-10 J18.9

05Laboratory Tests/lt53

Core metabolic and organ function

›Basic metabolic panel

›Sodium

›Hyponatremia < 135 mmol/l as poor prognostic marker

›Dilutional vs depletional etiology

›Potassium

›Hypokalemia risk with loop diuretics

›Hyperkalemia with RAAS blockade especially in CKD

›Creatinine and BUN

›Baseline renal function assessment

›Cardiorenal syndrome monitoring

›BUN:creatinine ratio for volume status

›Glucose

›Diabetic decompensation as precipitant

›Hepatic function

›Liver enzymes

›Congestive hepatopathy marker

›AST and ALT elevation in acute hepatic congestion

Cardiac biomarkers

›Natriuretic peptides

›BNP

›>= 100 pg/mL supports HF diagnosis

›> 400 pg/mL strongly supports decompensated HF

›Reduced sensitivity in obesity and HFpEF

›NT-proBNP

›<= 125 pg/mL effectively excludes HF (Class I recommendation)

›Age-adjusted thresholds for diagnosis

›< 55 years: >= 450 pg/mL

06Diagnostic Tests/dt101

Scoring Systems

›Ottawa Heart Failure Risk Score (OHFRS)

›Validated ED risk stratification tool

›Predicts 14-day serious adverse events

›High-risk features support admission

›High-risk criteria include

›SBP < 110 mmHg

›Oxygen saturation < 90% on presentation

›New ischemic ECG changes

›Creatinine >= 220 mmol/l

›Troponin elevation

›Score guides disposition decision

›Low OHFRS supports observation or discharge consideration

›ACEP Level B recommendation for validated risk tools

›NYHA Functional Classification

›Class I to IV severity grading

›Class I: no limitation with ordinary activity

›Class II: slight limitation with ordinary activity

›Class III: marked limitation, comfortable only at rest

›Class IV: symptoms at rest

›Used for GDMT eligibility and prognostication

›ACC/AHA Staging System

›Stage A: at risk, no structural disease

›Stage B: structural disease, no symptoms (pre-HF)

›Stage C: symptomatic HF

›Stage D: advanced refractory HF

›Hemodynamic Profile Classification

›Warm-dry, warm-wet, cold-dry, cold-wet profiles

›Guides acute management strategy

›Warm-wet: vasodilators and diuretics

›Cold-wet: inotropes plus diuretics

›Cold-dry: volume assessment, inotropes if needed

MRI

›Cardiac MRI indications

›Tissue characterization

›Myocarditis (gadolinium late enhancement pattern)

›Cardiac sarcoidosis (patchy mid-wall enhancement)

›Amyloidosis (global subendocardial enhancement)

›Hemochromatosis (T2 signal loss)

›Ischemic vs nonischemic cardiomyopathy

›Subendocardial or transmural scar in CAD distribution

›Mid-wall fibrosis in nonischemic cardiomyopathy

›Quantification of LVEF and volumes

›Most accurate non-invasive EF assessment

›Contraindications and limitations

›Non-MRI-compatible devices

›Some older ICDs and pacemakers

›LVAD constraints

›Hemodynamic instability precludes MRI

›Gadolinium contraindicated in GFR < 30 mL/min/1.73m2

›Clinical utility in HF

›Identifies etiology in 30% to 50% of new-onset cardiomyopathy

›Changes management in selected cases

›Not first-line in acute decompensation

›Echocardiography preferred acutely

CT

›Coronary CT angiography

›Ischemic etiology evaluation in new-onset HFrEF

›Alternative to invasive coronary angiography in low-intermediate risk

›Sensitivity > 95% for significant CAD

›Class IIa recommendation in 2022 AHA/ACC/HFSA guideline

›Contraindications

›Significant renal impairment (GFR < 30 mL/min)

›Inability to breath hold

›Irregular heart rhythm limits diagnostic quality

›CT chest non-contrast

›Pulmonary edema pattern assessment

›Bilateral ground-glass opacities

›Interlobular septal thickening (Kerley B equivalent)

›Bilateral pleural effusions

›Alternative diagnosis exclusion

›Pneumonia vs pulmonary edema

›Pulmonary embolism (with contrast)

›Diagnostic considerations

›CXR remains first-line for acute presentation

›CT when diagnosis uncertain or complication suspected

Ultrasound

›Point-of-care echocardiography

›Cardiac function assessment

›Gross LVEF estimation

›LV dilatation and wall motion abnormalities

›Pericardial effusion detection

›IVC size and collapsibility for volume assessment

›Limitations of POCUS vs formal echo

›Operator-dependent accuracy

›Limited diastolic function assessment

›Formal TTE required for complete evaluation

›Lung ultrasound

›B-line detection for pulmonary congestion

›>= 3 B-lines per zone in >= 2 bilateral zones

›Sensitivity 85% for pulmonary congestion

›Specificity 92% for cardiogenic pulmonary edema

›ACEP Level B recommendation

›Pleural effusion detection

›Superior to CXR in supine patients

›Effusion characterization (simple vs complex)

›Serial lung US for treatment response

›B-line reduction with effective diuresis

›Formal transthoracic echocardiography

›Class I recommendation in all new HF presentations

›LVEF quantification

›Valvular disease assessment

›Estimated pulmonary artery pressure

›Diastolic function grading

›Repeat TTE after GDMT optimization at 3 to 6 months

07Disposition/dispo54

Admission criteria

›ICU level indications

›Cardiogenic shock

›Vasopressor or inotrope requirement

›Mechanical circulatory support (IABP, Impella, ECMO)

›Respiratory failure

›Mechanical ventilation required

›High-flow nasal cannula with escalating requirement

›Hemodynamically significant arrhythmia

›Cardioversion or antiarrhythmic infusion needed

›Inpatient admission indications

›Significant hypoxia

›SpO2 < 92% on room air

›Escalating oxygen requirement

›New-onset HF requiring workup

›Etiology determination needed

›Echocardiography pending

›Inadequate ED response to initial therapy

›Persistent congestion after IV diuresis

›Hemodynamic instability

›Intermediate-risk features

›Tachycardia despite treatment

›Hyponatremia < 135 mmol/l

›Creatinine elevation

›Troponin elevation without ACS

›Markedly elevated BNP or NT-proBNP

Observation and discharge criteria

›Observation unit candidacy

08Treatment/t172

Immediate respiratory support

›Supplemental oxygen

›Nasal cannula for mild hypoxia

›Titrate to SpO2 94% to 98%

›Non-invasive ventilation for moderate to severe respiratory distress

›BiPAP: IPAP 10 to 12 cmH2O, EPAP 5 to 8 cmH2O

›CPAP: 5 to 10 cmH2O

›Reduces intubation rates (Class I recommendation)

›Decreases preload and LV afterload

›Intubation for refractory respiratory failure

›Rapid sequence intubation

›Ventilator settings: low tidal volume 6 mL/kg IBW

›PEEP 5 to 8 cmH2O to reduce LV afterload

Diuretics

›IV loop diuretics

›Furosemide IV

›Diuretic-naive: furosemide 20 to 40 mg IV

›Chronic diuretic users: 1 to 2.5 times home oral dose IV

›Reassess urine output and symptoms at 2 to 6 hours

›Target urine output 100 to 200 mL/hour initially

›Bumetanide IV

›0.5 to 2 mg IV

›Equivalent potency: bumetanide 1 mg = furosemide 40 mg

›Torsemide IV or PO

›10 to 20 mg IV or PO

›Higher bioavailability than furosemide

›Diuretic resistance management

›Sequential nephron blockade

›Metolazone 2.5 to 5 mg PO 30 minutes before loop diuretic

›IV chlorothiazide 250 to 500 mg IV

›Acetazolamide adjunct

›500 mg IV daily for 3 days (ADVOR trial evidence)

›Particularly in metabolic alkalosis

›Continuous infusion vs bolus dosing

›Furosemide infusion 5 to 40 mg/hour

›No significant outcome difference vs bolus in DOSE trial

›Higher doses associated with more diuresis

Vasodilators

›IV nitroglycerin

›Indication: hypertensive acute HF (SBP > 140 mmHg)

›Preload and afterload reduction

›Rapid symptom relief in flash pulmonary edema

›Dosing

›Start 10 to 20 mcg/minute IV

›Titrate by 10 to 20 mcg/minute every 5 to 10 minutes

›Maximum 200 mcg/minute

›Target SBP reduction 10 to 15 mmHg

›Contraindications

›SBP < 90 mmHg

›PDE5 inhibitor use within 24 to 48 hours

›Severe aortic stenosis (relative)

›IV nitroprusside

›Indication: refractory hypertensive HF or severe MR/AR

›Potent preload and afterload reduction

›Dosing

›Start 0.3 mcg/kg/min IV

›Titrate by 0.5 mcg/kg/min every 5 to 10 minutes

›Maximum 3 to 5 mcg/kg/min

›Arterial line monitoring recommended

›Toxicity concern

›Cyanide toxicity risk with prolonged high-dose use

›Avoid in severe renal or hepatic failure

›Nesiritide

›Recombinant BNP with vasodilatory effects

›2 mcg/kg IV bolus then 0.01 mcg/kg/min infusion

›Not shown to improve mortality (ASCEND-HF trial)

›Limited routine use

Inotropes and vasopressors

›Dobutamine

›Indication: low-output state, cardiogenic shock

›Positive inotrope and chronotrope

›Reduces filling pressures

›Dosing

›Start 2.5 mcg/kg/min IV

›Titrate by 2.5 mcg/kg/min every 5 to 10 minutes

›Usual range 5 to 15 mcg/kg/min

›Maximum 20 mcg/kg/min

›Cautions

›Tachyarrhythmia risk

›Increased myocardial oxygen demand

›Avoid in ischemic etiology if possible

›Milrinone

›Indication: cardiogenic shock, especially on beta-blocker

›PDE3 inhibitor, positive inotropy plus vasodilation

›Preferred in COPD or reactive airway disease

›Dosing

›0.125 to 0.75 mcg/kg/min IV

›No loading dose recommended in most cases

›Dose reduce in renal impairment

›Cautions

›Hypotension risk from vasodilation

›Tachyarrhythmia risk

›Renal clearance adjustment required

›Norepinephrine for refractory hypotension

›Indication: cardiogenic shock with vasodilation component

›Start 0.05 to 0.1 mcg/kg/min IV

›Titrate to MAP >= 65 mmHg

›Central venous access preferred

Guideline-directed medical therapy (GDMT) for HFrEF

›ARNI or ACE inhibitor or ARB

›Sacubitril/valsartan (ARNI) preferred

›Start 49/51 mg BID when tolerating ACEi/ARB

›Target 97/103 mg BID

›36-hour washout required when switching from ACEi

›Contraindicated with ACEi concurrently (angioedema risk)

›Class I recommendation (PARADIGM-HF trial evidence)

›Ramipril (ACEi) if ARNI not tolerated

›Start 2.5 mg BID, target 5 to 10 mg BID

›Losartan or valsartan (ARB) if ACEi intolerant

›Cough or angioedema as ACEi intolerance criteria

›Evidence-based beta-blocker

›Carvedilol

›Start 3.125 mg BID

›Target 25 mg BID (> 85 kg: 50 mg BID)

›Class I recommendation

›Metoprolol succinate

›Start 12.5 to 25 mg daily

›Target 200 mg daily

›Bisoprolol

›Start 1.25 mg daily

›Target 10 mg daily

›Initiate when euvolemic and hemodynamically stable

›Do not initiate in acute decompensation phase

›Mineralocorticoid receptor antagonist (MRA)

›Spironolactone

›Start 12.5 to 25 mg daily

›Target 50 mg daily

›Class I recommendation (RALES trial)

›Eplerenone

›Start 25 mg daily

›Target 50 mg daily

›Preferred in males (less gynecomastia)

›Contraindications

›Creatinine > 221 mmol/l or eGFR < 30 mL/min

›Potassium > 5.0 mmol/l

›SGLT2 inhibitor

›Dapagliflozin

›10 mg PO daily

›Class I recommendation (DAPA-HF trial)

›Benefit regardless of diabetes status

›Empagliflozin

›10 mg PO daily

›Class I recommendation (EMPEROR-Reduced trial)

›Benefits

›Reduces HF hospitalization and cardiovascular death

›Modest diuretic and natriuretic effect

›Slows CKD progression

›Cautions

›Hold during acute illness or surgery

›Genital mycotic infection risk

Additional therapies

›Hydralazine and isosorbide dinitrate

›Indication: intolerance to RAAS blockade (Class I)

›Especially in self-identified Black patients as additional therapy

›A-HeFT trial evidence

›Dosing

›Hydralazine 25 to 75 mg TID

›Isosorbide dinitrate 20 to 40 mg TID

›Ivabradine

›Indication: sinus rhythm, HR >= 70 bpm on maximum beta-blocker

›Start 5 mg BID

›Target 7.5 mg BID

›Class IIa recommendation

›Reduces HF hospitalization (SHIFT trial)

›IV iron replacement

›Ferric carboxymaltose IV

›Iron deficiency: ferritin < 100 mcg/L or TSAT < 20%

›Dose by weight and hemoglobin deficit

›Improves symptoms and quality of life (AFFIRM-AHF trial)

›Class IIa recommendation

›Device therapy

›ICD for primary prevention

›LVEF <= 35% after >= 3 months GDMT

›Class I recommendation

›CRT for cardiac resynchronization

›LBBB with QRS >= 150 ms on maximum GDMT

›Class I recommendation

›Improves EF and reduces mortality

09Special Populations/sp94

Pregnancy

›Peripartum cardiomyopathy

›Definition

›LVEF < 45% in final month of pregnancy or within 5 months postpartum

›No prior cardiomyopathy identified

›ICD-10 O90.3

›Incidence

›Approximately 1 in 1,000 to 4,000 live births

›Higher incidence in Black women, advanced age, multifetal pregnancy

›Recovery

›Partial or complete EF recovery in 50% to 70% within 6 months

›Recurrence risk in subsequent pregnancies

›Medication safety in pregnancy

›Safe: diuretics (furosemide) for acute pulmonary edema

›Short-term use for symptom relief appropriate

›Contraindicated: ACE inhibitors and ARBs

›Fetal renal agenesis and oligohydramnios risk

›Contraindicated: sacubitril/valsartan

›ARB component contraindicated in pregnancy

›Relatively safe: beta-blockers (metoprolol, carvedilol)

›Fetal growth restriction monitoring required

›SGLT2 inhibitors: not recommended in pregnancy

›Insufficient safety data

›Hydralazine and nitrates

›Preferred vasodilators in pregnancy

›Hydralazine 5 to 10 mg IV for acute hypertension

›Delivery and peripartum management

›Multidisciplinary team: cardiology, maternal-fetal medicine

›Fetal monitoring when viable gestation

›Anticoagulation if LVEF < 35% (thromboembolism risk)

›SpO2 target >= 95% to maintain fetal oxygenation

›Bromocriptine consideration

›Inhibits prolactin (proposed mediator in peripartum CMP)

›Class IIa recommendation in acute severe peripartum CMP

Geriatric

›Age-related physiologic changes

›Increased HFpEF prevalence

›Diastolic dysfunction predominates

›Age is primary risk factor for HFpEF

›Reduced kidney clearance

›Lower starting doses for all renally cleared agents

›Frequent electrolyte monitoring with diuresis

›Polypharmacy interactions

›NSAIDs commonly used and exacerbate HF

›QT prolongation risk higher

›Atypical presentation in older adults

›Fatigue and functional decline as primary complaint

›Dyspnea may be underreported due to reduced activity

›Delirium as presenting feature

›Low output or hypoxemia trigger

›Falls risk from orthostatic hypotension

›Blood pressure lowering medications

›GDMT tolerability in elderly

›Lower starting doses of ACEi, ARB, and ARNI

›Hypotension risk higher

›Spironolactone use with caution

›Gynecomastia, hyperkalemia, renal function decline

›SGLT2 inhibitors generally well tolerated

›Volume depletion and urinary tract infections more frequent

›Frailty and goals of care

›Advance directive discussion integral to HF management

›Palliative care involvement for advanced HF Stage D

Pediatrics

›Epidemiology and etiology in children

›Congenital heart disease most common cause

›Volume overload lesions (VSD, AV canal, truncus arteriosus)

›Pressure overload lesions (coarctation, AS)

›Dilated cardiomyopathy

›Viral myocarditis etiology common

›Genetic cardiomyopathies in infants and young children

›Acute decompensated HF in children

›AHA 2026 Scientific Statement on pediatric acute HF management

›Clinical presentation differences

›Infants

›Poor feeding and failure to thrive

›Diaphoresis with feeding

›Tachypnea as primary sign

›Hepatomegaly

›Older children

›Exercise intolerance and fatigue

›Peripheral edema

›Abdominal pain from hepatic congestion

›Treatment in children

›IV diuretics (weight-based)

›Furosemide 1 to 2 mg/kg IV per dose

›Maximum single dose 6 mg/kg in older children

›Inotropes (weight-based)

›Dobutamine 2 to 20 mcg/kg/min IV

›Milrinone 0.25 to 0.75 mcg/kg/min IV (no loading in most)

›ACE inhibitors in children (off-label in many ages)

›Enalapril 0.1 mg/kg/day divided BID

›Captopril 0.1 to 0.5 mg/kg/dose TID in neonates

›Carvedilol in pediatric DCM

›Starting dose 0.05 mg/kg BID, target 0.4 to 0.8 mg/kg BID

›GDMT evidence in children

›Limited compared to adults

›Pediatric cardiologist consultation essential

10Background/b85

Epidemiology

›Prevalence and incidence

›Approximately 6.7 million adults in the United States have HF

›Prevalence increases with age

›Affects > 10% of adults age 70 and older

›Most frequent cause of unplanned hospital admission in patients > 65 years

›1 million hospitalizations annually in the United States

›30-day readmission rate 20% to 25%

›Global burden

›Estimated 64 million people affected worldwide

›Rising incidence due to aging populations and improved MI survival

›Mortality data

›5-year mortality 40% to 50% after diagnosis

›Mortality comparable to many cancers

›Highest mortality in Stage D advanced HF

›HFrEF vs HFpEF outcomes

›HFrEF has higher cardiovascular mortality

›HFpEF has significant non-cardiac mortality

›HF subtype distribution

›HFrEF (LVEF <= 40%): approximately 40% to 50% of cases

›HFpEF (LVEF >= 50%): approximately 40% to 50% of cases

›HFmrEF (LVEF 41% to 49%): approximately 10% to 20%

Pathophysiology

›Neurohormonal activation

›RAAS activation

›Angiotensin II vasoconstriction and aldosterone release

›Sodium and water retention

›Ventricular remodeling (fibrosis, hypertrophy)

›Sympathetic nervous system activation

›Norepinephrine elevation causes tachycardia and vasoconstriction

›Compensatory initially, then maladaptive with chronic activation

›Beta-receptor downregulation with chronic exposure

›Natriuretic peptide system

›BNP and ANP released in response to wall stretch

›Counter-regulatory vasodilation and natriuresis

›Foundation for BNP and NT-proBNP diagnostic use

›Myocardial remodeling

›Eccentric hypertrophy in volume overload

›Chamber dilatation with sarcomere addition in series

›Mitral annular dilatation causing functional MR

›Concentric hypertrophy in pressure overload

›Sarcomere addition in parallel

›Diastolic dysfunction from reduced compliance

›Fibrosis and apoptosis

›Irreversible component of remodeling

›Target of GDMT (RAAS blockade slows fibrosis)

›Hemodynamic consequences

›Reduced cardiac output

›Inadequate oxygen delivery to peripheral tissues

›Compensatory peripheral vasoconstriction

›Elevated filling pressures

›Pulmonary venous hypertension causing congestion

›Pulmonary artery hypertension in chronic disease

›Right heart failure as late consequence

›Cardiorenal syndrome

›Reduced renal perfusion and venous congestion impair renal function

›Worsened by diuresis in some patients

Therapeutic Considerations

›GDMT rationale

›Neurohormonal blockade reverses remodeling

›ACEi, ARB, and ARNI reduce angiotensin II effects

›Beta-blockers reduce sympathetic activation

›MRA blocks aldosterone-driven fibrosis

›Simultaneous initiation of all four pillars recommended

›2024 ACC Expert Consensus supports rapid simultaneous uptitration

›Clinically significant benefit of each pillar is additive

›Target doses over 3 to 6 months

›EF improvement with GDMT

›Median EF improvement 10 to 15 percentage points

›Some patients normalize EF (LVEF > 50%)

›Decongestion principles

›IV diuretics cornerstone of acute management

›Symptom relief and outcomes improvement

›Loop diuretics act at thick ascending limb of Henle

›Diuretic resistance mechanisms

›Intestinal wall edema reduces oral absorption

›Distal nephron compensation

›Sequential nephron blockade addresses resistance

›Ultrafiltration in refractory congestion

›Mechanical fluid removal in diuretic-resistant patients

›CARRESS-HF trial: similar outcomes vs IV diuresis

›Reserved for truly refractory cases

›Evidence base highlights

›PARADIGM-HF: sacubitril/valsartan reduces mortality 20% vs enalapril

›DAPA-HF and EMPEROR-Reduced: SGLT2i reduces mortality and HF hospitalization

›RALES: spironolactone reduces mortality 30% in NYHA III-IV HFrEF

›MERIT-HF and COPERNICUS: metoprolol succinate and carvedilol reduce mortality 34%

›ADVOR trial: acetazolamide added to loop diuretics improves decongestion

11Patient Discharge Instructions/pdi32

copy discharge instructions

›Congestive heart failure home care

›Take all heart medications as prescribed every day

›Do not stop heart medications without talking to your doctor

›If you miss a dose, take it as soon as you remember unless it is almost time for the next dose

›Weigh yourself every morning before eating and after using the bathroom

›Write your weight down each day

›Call your doctor or go to the ER if your weight goes up more than 2 pounds in one day or 5 pounds in one week

›Limit salt (sodium) in your diet

›Avoid processed foods, canned soups, fast food, and added salt

›Limit sodium to less than 2,000 mg per day unless your doctor says otherwise

›Limit fluids if your doctor has told you to

›Generally 1.5 to 2 litres per day

›Count soups, ice cream, and gelatin as fluids

›Keep all follow-up appointments

›See your heart doctor or family doctor within 7 days of leaving the hospital

›Call within 48 to 72 hours to check in even if you feel well

›Warning signs to return to the emergency room

›Worsening shortness of breath at rest

›Cannot lie flat to sleep

›New or worsening leg swelling

›Weight gain of more than 2 pounds overnight or 5 pounds in a week

›Chest pain or pressure

›Fast or irregular heartbeat that is new or worse

›Feeling faint or passing out

›Confusion or unusual sleepiness

›Decreased urine output or no urine for more than 12 hours

›Activity and lifestyle

12References/r30

Guidelines and key sources

›Primary guidelines

›2022 AHA/ACC/HFSA Guideline for Management of Heart Failure (Heidenreich et al., JACC 2022)

›Comprehensive Class I to III recommendations for HFrEF, HFpEF, and HFmrEF

›2024 ACC Expert Consensus Decision Pathway for HFrEF Treatment (Maddox et al., JACC 2024)

›GDMT simultaneous initiation strategy

›2024 ACC Expert Consensus on Hospitalized HF Focused Update (Hollenberg et al., JACC 2024)

›In-hospital and discharge management

›Landmark clinical trials

›PARADIGM-HF (McMurray et al., NEJM 2014)

›Sacubitril/valsartan vs enalapril in HFrEF

›DAPA-HF (McMurray et al., NEJM 2019)

›Dapagliflozin in HFrEF

›EMPEROR-Reduced (Packer et al., NEJM 2020)

›Empagliflozin in HFrEF

›RALES (Pitt et al., NEJM 1999)

›Spironolactone in severe HFrEF

›ADVOR (Mullens et al., NEJM 2022)

›Acetazolamide plus loop diuretics for decongestion

›Emergency medicine evidence

›Rider I et al., Am J Emerg Med 2021

›Disposition of acute decompensated HF from the ED

›Deniau B et al., Eur Heart J 2023

›Acute HF pharmacological treatment review

›Ottawa Heart Failure Risk Score validation studies

›Stiell IG et al., CMAJ 2013

›Coding references

›ICD-10 I50.20 systolic HF unspecified

Evidence & Review