Acute heart failure

Last reviewed: 27 Oct 2022

Last updated: 25 Aug 2022

25 Aug 2022

New US guidance includes updated recommendations on classification of heart failure, prevention, and treatment of symptomatic disease

A joint guideline has been released by the American Heart Association, American College of Cardiology, and Heart Failure Society of America. Revised recommendations, based on contemporary evidence and acknowledging the increasingly diverse heart failure patient populations seen in practice, include:

A heart failure classification that includes heart failure with mildly reduced ejection fraction (HFmrEF; ejection fraction 41%-49%) and heart failure with improved ejection fraction (HFimpEF; previous ejection fraction ≤40% improved to >40% after follow-up measurement), alongside existing categories (heart failure with reduced ejection fraction [ejection fraction ≤40%] and heart failure with preserved ejection fraction [ejection fraction ≥50%])
Indications for temporary and durable mechanical circulatory support (MCS) in patients with advanced heart failure
Post-stabilization therapy for patients with heart failure with reduced ejection fraction (ejection fraction ≤40%) now includes drugs from four medication classes, including sodium-glucose cotransporter 2 (SGLT2) inhibitors (e.g., dapagliflozin or empagliflozin) regardless of whether they have type 2 diabetes mellitus.

See Management: approach

See Etiology

See Management: treatment algorithm

Original source of update

Acute heart failure is a clinical syndrome of reduced cardiac output, tissue hypoperfusion, increased pulmonary pressure, and tissue congestion.

Presents with dyspnea, decreased exercise tolerance, swelling of the legs, fatigue, and generalized weakness.

Clinical diagnosis is supported by ancillary tests such as ECG, chest x-ray, B-type natriuretic peptide, and echocardiogram. In cases where echocardiographic images are suboptimal or when an unusual cause of heart failure is suspected, and for diagnosis of specific cardiomyopathies, other tests (e.g., cardiac catheterization with hemodynamic measurements, computed tomography, and cardiac magnetic resonance imaging) are used.

Diuretics and oxygen are initial treatments for symptom relief. Cardiogenic shock may require vasoactive agents, mechanical ventilation, or mechanical circulatory support.

If acute myocardial infarction is present, early revascularization is essential.

Underlying cause or precipitant should be identified and treated.

Definition

Heart failure is defined clinically as a syndrome in which patients have symptoms and signs resulting from an abnormality of cardiac structure and/or function causing impairment of ventricular filling or ejection of blood.[1][2] Acute heart failure refers to rapid onset or worsening of symptoms and/or signs of heart failure, requiring urgent evaluation and treatment.[1]

History and exam

Key diagnostic factors

age >70 years
positive past medical history
dyspnea
pulmonary crepitations
peripheral edema
cool peripheries
chest pain
third heart sound (S3)

More key diagnostic factors

Other diagnostic factors

fatigue and weakness or decreased exercise tolerance
hypotension
tachycardia
elevated jugular venous pressure
displaced apex beat (point of maximal impulse)
dullness to percussion and decreased air entry in lung bases
wheezing
palpitations
cough
fever
syncope
murmur
ascites
hepatomegaly
central cyanosis

Other diagnostic factors

Risk factors

age >70 years
prior episode of heart failure
coronary artery disease
hypertension
valvular heart disease
pericardial disease
myocarditis
atrial fibrillation
diabetes mellitus
nonadherence to medications
excessive salt intake
excessive catecholamine stimulation
abnormal thyroid function
excessive alcohol intake

More risk factors

Diagnostic investigations

1st investigations to order

ECG
chest x-ray
Hb
thyroid function test
B-type natriuretic peptide
troponin
echocardiography
electrolyte panel with BUN, serum creatinine, glucose
lipid profile
liver function tests

More 1st investigations to order

Investigations to consider

cardiac catheterization
endomyocardial biopsy
cardiac magnetic resonance (CMR)
single-photon emission CT
positron emission tomography with or without CT
cardiac CT (coronary CT angiogram)
additional biomarkers

More investigations to consider

Treatment algorithm

ACUTE

hemodynamically stable

hypotensive (systolic BP <90 mmHg)

hypertensive crisis

ONGOING

acute episode stabilized: LVEF <50%

acute episode stabilized: LVEF ≥50%

Contributors

Authors

Syed Wamique Yusuf, MBBS, FACC, FRCPI

Professor of Medicine

Department of Cardiology

University of Texas

MD Anderson Cancer Center

Houston

Disclosures

SWY declares that he was a co-director of the American College of Cardiology (ACC) Cardiovascular Board Review Course during which he had also delivered lectures.

Acknowledgements

Dr Syed Wamique Yusuf would like to gratefully acknowledge Dr Daniel Lenihan, a previous contributor to this topic.

Disclosures

DL declares that he has no competing interests.

Peer reviewers

David Whellan, MD

Assistant Professor of Medicine

Jefferson Medical College

Philadelphia

Disclosures

DW declares that he has no competing interests.

Katherine C. Wu, MD

Assistant Professor of Medicine

Johns Hopkins University School of Medicine

Baltimore

Disclosures

KCW declares that she has no competing interests.

Sanjay Sharma, BSc (Hons), FRCP (UK), MD

Consultant Cardiologist

King's College Hospital London

London

Disclosures

SS declares that he has no competing interests.

Differentials
- Pneumonia
- Pulmonary embolism
- Asthma
More Differentials
Guidelines
- 2022 AHA/ACC/HFSA guideline for the management of heart failure
- Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute heart failure syndromes
More Guidelines
Patient leaflets
Atrial fibrillation
Atrial fibrillation: what is it?
More Patient leaflets
Videos
Central venous catheter insertion: animated demonstration
How to perform an ECG: animated demonstration
More videos
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Acute heart failure

New US guidance includes updated recommendations on classification of heart failure, prevention, and treatment of symptomatic disease

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

hemodynamically stable

hypotensive (systolic BP <90 mmHg)

hypertensive crisis

acute episode stabilized: LVEF <50%

acute episode stabilized: LVEF ≥50%

Contributors

Authors

Syed Wamique Yusuf, MBBS, FACC, FRCPI

Disclosures

Acknowledgements

Disclosures

Peer reviewers

David Whellan, MD

Disclosures

Katherine C. Wu, MD

Disclosures

Sanjay Sharma, BSc (Hons), FRCP (UK), MD

Disclosures

Differentials

Guidelines

Patient leaflets

Videos

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