Treatment of Acute Heart Failure : KSHF Guidelines

The Korean Society of Heart Failure (KSHF) has released its new guidelines on the treatment of Acute Heart Failure. In this part of the guideline, the treatment of AHF, including pharmacological and non-pharmacological therapies, monitoring, and discharge plan has been covered. In AHF patients with fluid retention, a prompt diuretic use is encouraged with careful monitoring of symptoms, electrolyte imbalance and renal function.

This guideline was developed based on previously issued international guidelines and amended to reflect the clinical situation in Korea. A committee of KSHF members decided on the format of the guideline, the selection of topics addressed, and the composition of the Writing Committee.

This guideline is intended to help improve clinical practice by providing recommendations based on clinical evidence. As such, the guideline does not serve as a basis for clinical judgement. The final decision in the treatment of each patient should be made by the treating physician according to their personal opinion and judgment while using the guideline to support these decisions.

1. PHARMACOLOGICAL TREATMENT

• General considerations


• Diuretics


• Intravenous vasodilators


• Intravenous inotropic agents and vasopressors


• Antiarrhythmic agents


• New drugs

2. DEVICE THERAPY AND SURGICAL TREATMENT

• Ultrafiltration


• Intra-aortic balloon pump


• Mechanical circulatory support and cardiac transplantation


• Surgical correction

3. MONITORING ACUTE HEART FAILURE PATIENTS

4. HOSPITAL DISCHARGE

• Treatment objective


• Improving quality of medical treatment using clinical quality indicators


• Management programs for heart failure patients


• Palliative care

General considerations

1. In HFrEF patients with acute exacerbation, the guideline-based medications should be continued if no hemodynamic instability or contraindications are evident (class of recommendation I, level of evidence B).


2. Low-dose beta-blockers should be started in stable patients who achieve an euvolemic state, after discontinuing the initial intravenous diuretics, vasodilators, and inotropic agents (class of recommendation I, level of evidence B).


3. If the clinical benefit of anticoagulant use is higher than the risk, anticoagulants should be used to prevent venous thrombosis (class of recommendation I, level of evidence B).

Diuretics

1. In AHF patients with fluid retention, a parenteral diuretic should be used with careful monitoring of symptoms, urine output, electrolyte balance, and renal function (class of recommendation I, level of evidence B).


2. In patients without oral diuretic therapy, the initial recommended dose of loop diuretics is furosemide 20–40 mg, and at least the same dosage of loop diuretics should be used in patients with acute exacerbation of CHF (class of recommendation I, level of evidence B).


3. The intermittent or continuous injection of diuretics is recommended, and the dose and duration should be adjusted according to the patient's symptoms and clinical condition (class of recommendation I; level of evidence B).


4. If symptoms do not improve even with loop diuretic use, it is advisable to add other diuretics such as thiazide or spironolactone (class of recommendation IIa, level of evidence B).

Intravenous vasodilators

1. Intravenous vasodilators may improve AHF symptoms in patients with systolic blood pressure >90 mmHg, and it is advisable that symptoms and blood pressure be monitored frequently during intravenous injection (class of recommendation IIa, level of evidence B).


2. In patients with hypertensive AHF, intravenous vasodilators can be used to improve patient symptoms and reduce congestion (class of recommendation IIa, level of evidence B).

Intravenous inotropic agents and vasopressors

1. To increase cardiac output, elevate blood pressure, and improve peripheral perfusion, short-term intravenous infusion of inotropic agents may be considered in patients with hypotension, signs/symptoms of hypoperfusion, or shock despite adequate filling status (class of recommendation IIa, level of evidence C).


2. If the cause of hypoperfusion is related to the use of beta-blockers, the use of the phosphodiesterase antagonist, milrinone may be considered under continuous electrocardiographic and arterial blood pressure monitoring (class of recommendation IIb, level of evidence C).


3. In patients with persistent cardiogenic shock despite the use of intravenous inotropic agents, the use of vasoconstrictors such as dopamine or norepinephrine to increase blood pressure and blood flow to major organs may be considered under continuous electrocardiography and arterial blood pressure monitoring (class of recommendation IIb, level of evidence C).


4. In HF patients with pulmonary congestion, intravenous inotropic agents should not be used unless there is hypotension, signs of hypoperfusion to major organs, or shock, because it may cause serious arrhythmias or myocardial ischemia leading to death (class of recommendation III, level of evidence C).

Antiarrhythmic agents

1. Digoxin use is advised in patients with AHF and atrial fibrillation (class of recommendation IIa, level of evidence C).


2. The use of amiodarone can be considered in the presence of atrial fibrillation concomitant with AHF (class of recommendation IIb, level of evidence B).


3. Other antiarrhythmic agents except for amiodarone should not be used to treat atrial and ventricular tachyarrhythmia (class of recommendation III, level of evidence A).

New drugs

1. In patients with AHF, vasopressin receptor antagonists may be considered when severe hyponatremia persists despite appropriate treatment including water restriction (class of recommendation IIb, level of evidence B).

Ultrafiltration

1. Ultrafiltration may be used to remove excessive fluid and improve congestion symptoms in AHF patients with fluid retention (class of recommendation IIb, level of evidence B).


2. Ultrafiltration may be considered in patients with congestive HF unresponsive to conventional medical therapy (class of recommendation IIb, level of evidence C).

Intra-aortic balloon pump

1. It is reasonable to use an intra-aortic balloon pump (IABP) in patients with AHF in a state of cardiogenic shock due to mechanical causes (e.g., ventricular septal rupture, acute mitral insufficiency) accompanied by acute myocardial infarction (AMI) (class of recommendation IIa, level of evidence C).


2. The routine use of IABP in patients with AHF and cardiogenic shock accompanied by AMI is not recommended (class of recommendation III, level of evidence B).

Mechanical circulatory support and cardiac transplantation

1. It is reasonable to use extracorporeal life support (ECLS) in patients with AHF and acute cardiac arrest refractory to existing drug therapies (class of recommendation IIa, level of evidence B).


2. It is reasonable to use ECLS when HF is unresponsive to drug treatment and progresses to cardiogenic shock (class of recommendation IIa, level of evidence B).


3. It is reasonable to use a percutaneous ventricular assist device before deciding the indication for cardiac transplantation or implantation of a left ventricular assist device (LVAD) in patients who are hemodynamically unstable and suspected to have organ damage (class of recommendation IIb, level of evidence B).

For more details click on the link: https://doi.org/10.4070/kcj.2018.0349