The Management of Acute Heart Failure From June 2013 ACCEL

The following resource is from the June 2013 American College of Cardiology Extended Learning (ACCEL) notes accompanying the June mp3s lectures available at (requires subscription).

How Do I Manage Worsening Heart Failure by Dr. Anita Dewal

Anita Dewal MD states (what follows are all direct quotes of the lecture notes)

Take-home Messages.

✹ Treating the signs and symptoms of congestion in acute decompensated HF is often complicated by worsening renal function.

✹ Recent trials have failed to demonstrate any new approach to managing these patients.

✹ The best approach to patients with worsening renal function in the presence of congestion appears to be stepped pharmacological care.

About one-fourth of patients with acute decompensated HF (ADHF) develop renal dysfunction during their admission. A number of mechanistic pathways have been suggested to explain this worsening of renal function, including low cardiac output, elevation of central venous pressure,renin-aldosterone-angiotensin system (RAAS) dysfunction, sympathetic overactivity, oxidative injury, and reduced renal perfusion.

Given the close association between reduction in intravascular volume and worsening renal function, diuresis during treatment for ADHF has been inferred to be the cause of renal dysfunction. However, emerging data argue against this concept. Even the long-term prognostic significance of worsening renal function during treatment of ADHF is debatable.

Back to Basics—Management of Acute Heart Failure

So, what’s the best approach for worsening renal function in the setting of ADHF? Dr. Deswal suggests a back-to-basics approach.

First step is to rule out contributing factors, such as nonsteroidal anti-inflammatory drugs and nephrotoxic antibiotics (such as the combination of sulfamethoxazole and trimethoprim); acute kidney injury secondary to contrast agents; urinary tract obstruction; angiotensinconverting enzyme inhibitors in patients with bilateral renal artery stenosis; or acute tubular necrosis secondary tohypotension/hypovolemia.

In the event of worsening renal function, confirm the volume status: Is the patient still congested? Is the patient overdiuresed? The ACCF/AHA guidelines for managing HF suggest it is appropriate to onsider invasive hemodynamic monitoring for carefully selected patients with ADHF with persistent symptoms despite empiric adjustment of standard therapies and whose renal function

is worsening with therapy or whose fluid status, perfusion, or systemic/pulmonary vascular resistances are uncertain. (This recommendation is given a class IIa designation and level of evidence of C.)

The Heart Failure Society of America guidelines state that “patients with moderate to severe renal dysfunction and evidence of fluid retention should continue to be treated with diuretics. In the presence of severe fluid overload, renal dysfunction may improve with diuresis.” (Level of evidence C)

Dr. Deswal also suggested using the stepped pharmacological care used in CARRESS-HF, for which she served as an investigator. The National Heart, Lung, and Blood Institute

Heart Failure Clinical Research Network designed the trial using the approach in the accompanying table.(3) The goal for urine output was 3-5 L/day, and if output was less than this, the trial design instructed investigators to advance to the next step on the grid. If urine output at 48 hours was still

<3 L/day, consider dopamine or dobutamine at 2 mcg/kg/min if systolic blood pressure is <110 mm Hg and EF is <40% or there is right ventricular systolic dysfunction. If systolic blood pressure is >120 mm Hg (at any EF) and there are severe symptoms, then consider nitroglycerine or nesiritide.

Current Daily Dose Loop Dose Thiazide
A. 80 mg 40 mg IV bolus +5 mg/hour None
B. 81-160 mg/day 80 mg IV bolus +10 mg/hour 5 mg metolazone/day
C. 161– 240 mg 80 mg IV bolus +20 mg/hour 5 mg metolazonetwice/day
D. >240 mg/day 80 mg IV bolus +30 mg/hour 5 mg metolazonetwice/day

Bart et al. J Card Fail 2012;18:176-82


1. Ather S, Bavishi C, McCauley MD, et al. Worsening renal function is not associated with response to treatment in acute heart failure. Int J Cardiol 2012 May 24. [Epub ahead of print]

2. Patarroyo M, Wehbe E, Hanna M, et al. Cardiorenal outcomes after slow continuous ultrafiltration therapy in refractory patients with advanced decompensated heartfailure. J Am Coll Cardiol 2012;60:1906-12.

3. Bart BA, Goldsmith SR, Lee KL, et al. Cardiorenal rescue study in acute decompensated heart failure: rationale and design of CARRESS-HF, for the Heart Failure Clinical Research Network. J Card Fail 2012;18:176-82.

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