Congestive Heart Failure - Madeleine Alder


  • HFrEF
    • Ischemic (40%): Obstructive CAD, previous/current myocardial infarction
    • NICM (60%): HTN, idiopathic, myocarditis, genetic/familial, valvular, tachycardia/PVC-induced, infiltrative (amyloid, sarcoid, hemochromatosis), Takotsubo/stress cardiomyopathy, peripartum CM, substance abuse, chemotherapy/toxin-induced, "burned out" hypertrophic cardiomyopathy
  • HFpEF: HTN, CAD, obesity, DM, infiltrative, hypertrophic cardiomyopathy
  • Causes of Heart Failure Exacerbations (FAILURES)
    • Forgetting medications or taking drugs that can worsen HF (e.g. BB, CCB, NSAIDs, TZDs), chemo (anthracyclines, trastuzumab)
    • Arrhythmia: AF, VT, PVCs; Increased arrhythmia burden on device check?
    • Ischemia or Infarction or Infection; myocarditis; Acute vascular dysfunction (e.g. endocarditis), especially mitral or aortic regurgitation.
    • Lifestyle choices: Dietary indiscretions - high salt, EtOH, excessive fluid intake. Obesity.
    • Upregulation (pregnancy and hyperthyroidism)
    • Renal failure: acute, progression of CKD, or insufficient dialysis (Increased preload)
    • Embolus (pulmonary) or COPD (leads to increase right-sided afterload)
    • Stenosis (worsening AS, RAS) leading to hypertensive crisis high left-sided afterload


  • Congestion: shortness of breath, dyspnea on exertion, Orthopnea, PND
  • Nausea/poor po intake
  • Confusion
  • Exam: Edema (legs, sacrum); Rales, S3, S4, murmur (AS, MR), Elevated JVD, + Hepatojugular reflex, Ascites


  • CBC, CMP, Magnesium 
  • Lactate, Troponin, BNP
  • Pro-BNP if on Entresto)
  • TSH
  • Iron studies
  • EKG
  • CXR, TTE
  • Determine Hemodynamic Profile 


                     Volume Status





Cardiac Index


Warm Extremities


Adequate Urine Output


Normal Pulse Pressure

Warm and Dry

Forrester Class I

Warm and Wet

Forrester Class II



Cardiac Index

Cardiogenic Shock


Cool Extremities


Renal Failure


Narrow Pulse Pressure

Cold and Dry

Forrester Class III

Cold and Wet

Forrester Class IV


  • Telemetry, Daily STANDING weights, 2 L fluid restriction, 2g sodium diet, Strict I/Os 
  • Cold and Wetà may require ionotropic support or transfer to the CCU
  • Warm and Wet à Diuresis
    • Diuresis: Place on 2.5 x home dose of IV diuretic, dose BID-TID (DOSE Trial)
      • Goal is to be net negative (generally 1-2 L per day, but patient dependent)
      • Check BMP and Mg BID and keep K>4 and Mg>2
      • Monitor UOP and weights to determine if dosing adequate
      • Low threshold for substantial increase (double) in loop vs transition to drip
      • Can also augment with sequential nephron blockade (thiazides, acetazolamide)


 Goal-Directed Medical Therapy


  • Blocks harmful effects of renin-angiotensin-aldosterone system activation and attenuates adverse cardiac and vascular remodeling
  • If planning on using Entresto eventually, favor ARB over ACE-i in short term
  • Sacubitril-valsartan (Entresto):  Additional benefit of Neprilysin inhibition
    • 36-hour washout after stopping ACE-i before starting Entresto to avoid angioedema

Aldosterone receptor antagonists

  • Diuretic and blood pressure lowering effects and blocks deleterious effects of aldosterone on the heart (including hypertrophy and fibrosis)
  • May also reduce hospitalizations in HFpEF
  • Worry about hyperkalemia: avoid if CrCl<30 or K>5


  • Reduces catecholamine stimulation including elevated heart rate, increased myocardial energy demands, adverse remodeling due to cardiac myocyte hypertrophy and death
  • Mortality benefit shown with carvedilol, metoprolol succinate or bisoprolol
  • Avoid if pt is decompensated (cold); “start low and go slow”
  • Can continue during exacerbation if patient compensated, (ie not in shock)

Hydralazine/Isosorbide Dinitrate

  • Reduces cardiac afterload and preload and may also enhance nitric oxide bioavailability
  • Reduction in mortality for African American patients

SGLT-2 inhibitors

  • Osmotic diuresis and natriuresis, improve myocardial metabolism, inhibit sodium-hydrogen exchange in myocardium, reduce cardiac fibrosis

Cardiac resynchronization therapy (CRT)

  • Criteria: HFrEF with LVEF ≤35%, QRS ≥150 ms with left bundle branch block (LBBB); NYHA class II to ambulatory class IV HF and wide QRS

Mitra Clip

  • Criteria: mitral regurgitation of 3-4+, on maximally tolerated GDMT, an ejection fraction >20%, and a left ventricle end-systolic dimension of less than 7 cm

Iron repletion

  • Criteria: ferritin <100 µg/L or ferritin 100-299 µg/L AND transferrin saturation <20%.
  • Replete intravenous (IV) iron. IV iron sucrose (500 mg x2 doses 48 hours apart) or ferric carboxymaltose (maximum dose of 1000 mg per week) or iron dextran (1 g x1)


Additional Information:

  • ICD placement (See Below, eg Cardiac Devices)
  • Starting patients on low dose of multiple agents preferred to max dose of single agent
  • D/C summary should have discharge weight, diuretic regimen, and renal function
  • Daily weights at home with rescue diuretic plan (pm dose for 3 lbs in 1 day, 5 lbs in 3 days)