This document provides an overview and guidelines for the management of acute heart failure during hospitalization. It discusses evaluating the patient's volume status and filling pressures, starting intravenous diuretics and nitrates for initial stabilization, monitoring the patient daily and assessing response to treatment, identifying and treating the underlying cardiac cause, and ensuring proper long-term medication and management upon discharge to reduce risk of readmission. Rapid improvement in symptoms, filling pressures, and pulmonary congestion as estimated by combined echocardiography and lung ultrasound during the early treatment course can help determine treatment response and prognosis.

1. How to make the most out of hospital stay
Acute heart failure management: essentials for
clinician
Veli-Pekka Harjola
FHFA, FESC
Helsinki University Hospital, Finland

2. Conflicts of interest
• none declared

3. The common heart failure patient
• 75-year old man with
• hypertension, lipid disorder, ex-smoker, anemia,
osteoarthrosis
• AS, AFib, CAD, CKD, COPD, DM, TIA and …

4. Chioncel O. Am Heart J 2011;162:142

5. Use of iv therapies during first 48 hours
and in-hospital mortality
Mebazaa A. Intensive Care Med (2011) 37:290–

6. Goals of treatment
McMurray J. European Journal of Heart Failure (2012) 14, 803–
Mobilize the patient

7. Risk assessment: Independent
predictors of in-hospital mortality
Tavazzi L et al. EHJ 2006; 27:1207

8. Acute medication
• initial stabilization
• goal-directed therapy with adequate doses
– furosemide iv or infusion
– nitrate infusion or patches

9. Check-list for management of AHF
1. ensure vital functions
2. evaluate volume and filling status,
hypoperfusion & clinical profile
3. optimize myocardial oxygen
consumption and delivery
4. start CPAP, iv-furosemide, nitrate
5. study the cause and mechanism of
HF (echocardiography)
6. treat precipitating factors
7. continuosly check the response to
therapy often and increase intensity
rapidly as needed (levosimendan)

10. Cardiac cause
• echocardiography
– bed-side in ED
– comprehensive on ward
• ischemic heart disease
– how to interpret troponins
– coronary angiogram: to whom and when
• indications for CRT, ICD?
• telemetry

13. Inhospital monitoring
• Patient should be weighed daily and have an
accurate fluid balance chart completed
• Standard noninvasive monitoring of pulse,
respiratory rate and blood pressure should be
performed
• Renal function and electrolytes should be
measured daily
• Pre-discharge measurement of BNP is useful
for post-discharge planning
Mebazaa A. Published on-line in Eur J HF and EHJ 2015

14. Decongestion and 60-day risk
of ED visit, re-hospitalization, or death
Kociol HD. Circ HF 2014
4 lbs=1.8kg

15. Use of echo and ultrasound techniques vs
symptoms for monitoring?

16. Thoracic FAST protocol vs VAS
- 70 AHF patients
- followed up with serial FAST protocol &
VAS scores 0,12,24,48h and discharge
- The FAST protocol was positive
if E/e`was >15 and a congestive LUS
- (bilateral B-lines (BL) or pleural fluid (PF) right sided or
bilaterally)
- “Responders" became asymptomatic at rest and capable of
walking > 20 meters during hospital stay
- LUS was considered normalized when absent of PF and
bilateral BL
Öhman J 1; Harjola V-P 2; Lassus J 3; Karjalainen P. HFA 2015.

17. Rapid improvement of symptoms, filling pressures and
pulmonary congestion estimated by combined echo and lung
US protocol during early course of AHF treatment
Öhman J 1; Harjola V-P 2; Lassus J 3; Karjalainen P. HFA 2015.

18. Goals of treatment
McMurray J. European Journal of Heart Failure (2012) 14, 803–
Mobilize the patient

19. Prognostic medication
HefREF
• betablockers, ACEI/ARB,
spironolactone/eplerenone, ivabradine
according to guidelines
• decompensated CHF: continue at the highest
possible dose
• in de-novo: start low, aim high
• good opportunity for up-titration in both

20. Maggioni AP. EJHF 2010; 12:1076

21. Role of beta-blockers in patients
admitted for worsening heart failure
Orso F. EJHF 2009; 11: 77
before admission / during hospital stay

22. Oral medication in
normo/hypertension
Appropriate adjustment by kalemia and renal
function
Mebazaa A. Published on-line in Eur J HF and EHJ 2015

23. Long term medication
HefREF
• adequate treatment of underlying disease
(hypertension)
• rate control of Afib
• symptomatic medication (diuretics)

24. Concomitant medication
• Anticoagulation in afib patients
• Antidiabetics
• Bronchodilators
• NSAIDs
• Antidepressants
• Harms, interactions – clean up the drug list !

25. Goals of treatment
McMurray J. European Journal of Heart Failure (2012) 14, 803–
Mobilize the patient

26. That’s what it’s all about !

27. ThankThank youyou

28. Back up slide

29. Change from admission to discharge
All Responders
Non-
responders
Patients 70 39 (56 %) 31 (44%) P
LUS responsiveness (%) 59 85 (PPV 80%) 26 (NPV 79%) <0.001
Δ E/e` 3,01 4,44 1,09 0.004
Δ IVC (grades 1-3) 0,53 0,74 0,26 0.012
Final E/e 17,9 15,3 21,2 <0.001
Final IVC 0,69 0,38 1,10 <0.001
Cumul. fluid loss
(kg/liters) 2,91 3,89 1,59 <0.001
Δ systolic blood pressure
(mmHg) 18,6 26,7 4,65 0,001
Δ MAP (mmHg) 11,1 20,0 -0,10 <0.001
Δ pulse (/min) 10,2 17,0 1,71 0.002
HFA 2015. Öhman J 1; Harjola V-P 2; Lassus J 3; Karjalainen P 1