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Evaluation of the causes of heart failure• ECG: evidence for CAD, LVH, LAE, heart block or low voltage (? infiltrative CMP/DCMP)• Coronary angiography (or ? CT coronary angiography)• If no CAD, w/u for nonischemic DCMP, HCMP, or RCMP (see “Cardiomyopathies”)Precipitants of acute heart failure• Myocardial ischemia or infarction; myocarditis• Renal failure (acute, progression of CKD, or insufficient dialysis) S cpreload• Hypertensive crisis (incl. from RAS), worsening AS Scleft-sided afterload• Dietary indiscretion or medical nonadherence• Drugs (B, CCB, NSAIDs,TZDs) or toxins (EtOH, anthracyclines)• Arrhythmias; acute valvular dysfxn (eg, endocarditis), espec. mitral or aortic regurgitation• COPD or PE S cright-sided afterload• Anemia, systemic infection, thyroid diseaseTreatment of acute decompensated heart failure• Assess degree of congestion & adequacy of perfusion• For congestion: “LMNOP”Lasix w/ monitoring of UOP; high-dose(IVB 2.5 PO dose) vs. low-dose (IVB1 PO dose) S cUOP but transientc in renal dysfxn; ∅ clear diff betweencont vs. intermittent (DOSE,ACC 2010)Morphine (T sx, venodilator, T afterload)Nitrates (venodilator)Oxygen noninvasive ventilation (see “Mechanical Ventilation”)Position (sitting up & legs dangling over side of bed S Tpreload)• For low perfusion, see belowTreatment of advanced heart failure (Circ 2009;119:e391)• Tailored Rx w/ PAC (qv); goals of MAP 60, CI 2.2 (MVO 2 60%), SVR 800, PCWP 18• IV vasodilators: NTG, nitroprusside (risk of coronary steal in Pts w/ CAD;prolonged use S cyanide/thiocyanate toxicity); nesiritide (rBNP) T PCWP & sx,but may c Cr & mortality (JAMA 2002;287:1531 & 2005;293:1900)• Inotropes (properties in addition to c inotropy listed below)dobutamine: vasodilation at doses 5 g/kg/min; mild T PVR; desensitization over timedopamine: splanchnic vasodil. ScGFR & natriuresis; vasoconstrict. at 5 g/kg/minmilrinone: prominent systemic & pulmonary vasodilation; T dose by 50% in renal failure• Ultrafiltration: 1 L fluid loss at 48 h and 50% T in rehosp. (JACC 2007;49:675)• Mechanical circulatory supportintraaortic balloon pump (IABP): deflates in diastole & inflates in systole to T impedenceto LV ejection of blood & c coronary perfusionventricular assist device (LVAD RVAD): as bridge to recovery (NEJM 2006;355:1873) ortransplant (some temporary types can be placed percutaneously PVAD), or asdestination therapy (45–50% T mort. vs. med Rx; NEJM 2001;345:1435 & 2009;361:2241)• Cardiac transplantation: 15–20% mort. in 1st y, median survival 10 yRecommended Chronic Therapy by CHF Stage (Circ 2009;119: e391)Stage (Not NYHA Class) Pt Characteristics TherapyHigh risk for HF HTN, DM, CAD Treat HTN, lipids, DM, SVTA Structural heart dis. Cardiotoxin exposure Stop smoking, EtOHAsx FHx of CMP Encourage exerciseACEI if HTN, DM, CVD, PADB Structural heart dis. Prior MI, T EF, LVH All measures for stage AAsx or asx valvular dis. ACEI & B if MI/CAD or T EF Structural heart dis.All measures for stage ACDOvert HFACEI, B, diuretics, Na restrictConsider aldactone, ICD, CRTConsider nitrate/hydral, digoxinRefractory HF Sx despite maximal All measures for stage A–C Symptoms of HF(prior or current)Low perfusion?Yes NoCongestion?Norequiring specialized medical Rx IV inotropes,VAD, transplantinterventions 4 yr mortality 50% End-of-life care(Circ 2009;119:e391)• No clear evidence that BNP-guided Rx results in superior clinical outcomes outsideof encouraging intensification of established therapies (JAMA 2009;301:383)• Implantable PA pressure sensor may T risk of hosp (CHAMPION, HF Congress 2010)YesWarm & Dry Warm & WetOutPt Rx Diuresis vasodilatorCold & Dry Cold & Wet Inotropes Tailored Rx(CCU) (CCU)HF 1-15