HFSA 2010 Comprehensive Heart Failure Practice Guideline

Lindenfeld, Jo Ann; Nm, Albert; Jp, Boehmer; Collins, Sean P.; Ezekowitz, JA; Mm, Givertz; Sd, Katz; Klapholz, Marc; Moser, DK; Jg, Rogers; Rc, Starling; Wg, Stevenson; Tang, WH Wilson; Teerlink,; Mn, Walsh

doi:10.1016/j.cardfail.2010.04.004

Cited by 1,031 publications

(412 citation statements)

References 166 publications

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“…Intravenous loop diuretics form the mainstay of decongestive therapy, but unfortunately, resistance to these agents is common 3. Both US and European Heart Failure (HF) guidelines state that when diuresis remains inadequate with loop diuretic therapy, either escalation of loop diuretic dose or the addition of a thiazide diuretic may be considered to intensify the regimen, yet these recommendation are based on limited data to support the relative safety of each appraoch 4, 5, 6. Notably, sequential nephron blockade further limits the ability of the kidney to regulate fluid and electrolyte excretion beyond loop diuretic monotherapy, potentially leading to complications such as hyponatremia, hypokalemia, and worsening renal function (WRF) 7, 8, 9, 10…”

Section: Introductionmentioning

confidence: 99%

Outcomes Associated With a Strategy of Adjuvant Metolazone or High‐Dose Loop Diuretics in Acute Decompensated Heart Failure: A Propensity Analysis

Brisco‐Bacik

Maaten

Houser

et al. 2018

JAHA

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BackgroundIn acute decompensated heart failure, guidelines recommend increasing loop diuretic dose or adding a thiazide diuretic when diuresis is inadequate. We set out to determine the adverse events associated with a diuretic strategy relying on metolazone or high‐dose loop diuretics.Methods and ResultsPatients admitted to 3 hospitals using a common electronic medical record with a heart failure discharge diagnosis who received intravenous loop diuretics were studied in a propensity‐adjusted analysis of all‐cause mortality. Secondary outcomes included hyponatremia (sodium <135 mEq/L), hypokalemia (potassium <3.5 mEq/L) and worsening renal function (a ≥20% decrease in estimated glomerular filtration rate). Of 13 898 admissions, 1048 (7.5%) used adjuvant metolazone. Metolazone was strongly associated with hyponatremia, hypokalemia, and worsening renal function (P<0.0001 for all) with minimal effect attenuation following covariate and propensity adjustment. Metolazone remained associated with increased mortality after multivariate and propensity adjustment (hazard ratio=1.20, 95% confidence interval 1.04–1.39, P=0.01). High‐dose loop diuretics were associated with hypokalemia and hyponatremia (P<0.002) but only worsening renal function retained significance (P<0.001) after propensity adjustment. High‐dose loop diuretics were not associated with reduced survival after multivariate and propensity adjustment (hazard ratio=0.97 per 100 mg of IV furosemide, 95% confidence interval 0.90–1.06, P=0.52).ConclusionsDuring acute decompensated heart failure, metolazone was independently associated with hypokalemia, hyponatremia, worsening renal function and increased mortality after controlling for the propensity to receive metolazone and baseline characteristics. However, under the same experimental conditions, high‐dose loop diuretics were not associated with hypokalemia, hyponatremia, or reduced survival. The current findings suggest that until randomized control trial data prove otherwise, uptitration of loop diuretics may be a preferred strategy over routine early addition of thiazide type diuretics when diuresis is inadequate.

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Section: Introductionmentioning

confidence: 99%

Outcomes Associated With a Strategy of Adjuvant Metolazone or High‐Dose Loop Diuretics in Acute Decompensated Heart Failure: A Propensity Analysis

Brisco‐Bacik

Maaten

Houser

et al. 2018

JAHA

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“…Patients were excluded if they were on dialysis, were transferred from another acute care hospital, had an active Do Not Resuscitate order on hospital presentation or admission, had known severe aortic stenosis, if key data were missing, or if they were non‐Ontario residents. Conservatively, we also excluded those with systolic blood pressure <100 mm Hg or diastolic blood pressure <60 mm Hg on presentation to the hospital, since nitrates are cautioned in the presence of hypotension 18. We excluded those who died prior to hospital admission since their foreshortened stay would limit the opportunity to administer nitrates in the hospital.…”

Section: Methodsmentioning

confidence: 99%

Impact of Nitrate Use on Survival in Acute Heart Failure: A Propensity‐Matched Analysis

Parker

Austin

et al. 2016

JAHA

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BackgroundThere is limited evidence that the use of nitrates in acute decompensated heart failure early after presentation to a hospital can improve clinical outcomes. We aimed to determine whether early nitrate exposure is associated with improved survival in a large retrospective cohort study.Methods and ResultsWe examined 11 078 acute decompensated heart failure patients who presented to emergency departments in Ontario, Canada, between 2004 and 2007, in the Enhanced Feedback For Effective Cardiac Treatment and the Emergency Heart failure Mortality Risk Grade studies. In propensity‐matched analyses, we examined the effect of nitrate administration in the acute emergency department setting for its impact on death at 7, 30, and 365 days. In propensity‐matched analyses, we found no difference in survival between those who received nitrates in the emergency department and the non‐nitrate comparator group. Hazard ratios for mortality were 0.76 (95% CI; 0.51, 1.12) over 7 days, 0.97 (95% CI; 0.77, 1.21) over 30 days, and 0.91 (95% CI; 0.82, 1.02) over 1 year of follow‐up. There was no significant difference in survival or hospital length of stay between nitrate and non‐nitrate controls in extended follow‐up. There was also no significant effect of nitrates in subgroups stratified by presence of chest pain, troponin elevation, chronic nitrate use, and known coronary artery disease.ConclusionsIn acute decompensated heart failure, use of nitrates acutely in the emergency department setting was not associated with improvement in short‐term or near‐term survival. Our study does not support generalized use of nitrates when the primary goal of therapy is to reduce mortality.

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“…Curricula for the education of the SHU staff were adapted from the Bridge Program, an ongoing initiative in a Midwestern university hospital system, that has produced evidence of improvement in HF-related knowledge among the staff (Boxer et al, 2012). Educational resources put forth by the Heart Failure Society of America and the American Heart Association were used for patient/family education program (Lindenfeld et al, 2010).…”

Section: Skilled Heart Unit Model Of Carementioning

confidence: 99%

Implementation of a Heart Failure Quality Initiative in a Skilled Nursing Facility: Lessons Learned

Nazir¹,

Dennis²,

Unroe³

2015

J Gerontol Nurs

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Skilled nursing facilities (SNFs) are organizations that represent complex adaptive systems, offering barriers to the implementation of quality improvement (QI) initiatives. The current article describes the authors’ efforts to use the approach of reflective adaptive process to implement a new model of care (i.e., the Skilled Heart Unit Program) for effective heart failure (HF) care in one SNF. A team of stakeholders from the local hospital system and a local SNF was convened to design and implement this new model. Evaluation of the implementation processes confirmed the value of the implementation approach, which centered on team-based approaches, staff engagement, and flexibility of processes to respect the SNF’s needs and culture. Interviews with facility staff and the administrator revealed their perceptions that the strategy resulted in better HF care, enhanced teamwork between staff and clinicians, and improved staff job satisfaction. This work provides a unique blueprint of strategic QI implementation for patients with HF in the SNF setting. [ Journal of Gerontological Nursing, 41 (5), 26–33.]

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HFSA 2010 Comprehensive Heart Failure Practice Guideline

Cited by 1,031 publications

References 166 publications

Outcomes Associated With a Strategy of Adjuvant Metolazone or High‐Dose Loop Diuretics in Acute Decompensated Heart Failure: A Propensity Analysis

Outcomes Associated With a Strategy of Adjuvant Metolazone or High‐Dose Loop Diuretics in Acute Decompensated Heart Failure: A Propensity Analysis

Impact of Nitrate Use on Survival in Acute Heart Failure: A Propensity‐Matched Analysis

Implementation of a Heart Failure Quality Initiative in a Skilled Nursing Facility: Lessons Learned

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