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Last Updated: 11/22/2013  

Heart Failure

  • Use echocardiography to screen for valvular heart disease in patients with significant murmurs. Do not use echocardiography to screen for heart failure in asymptomatic patents without murmurs.

  • Obtain an electrocardiogram and chest x-ray in patients with suspicion for heart failure to aid in diagnosis and provide insight into the cause of ventricular dysfunction.

  • Perform echocardiography and use results to define the type and extent of ventricular dysfunction and to identify potentially reversible causes of heart failure.

  • Use exercise testing to confirm functional capacity in heart failure, to look for ischemia, and to differentiate it from other conditions

  • Order laboratory studies to aid in diagnosis or to identify secondary causes of heart failure, including electrolytes, blood counts, and thyroid studies.

  • Advise patients with heart failure to limit salt to 2 g sodium and fluid intake to 2 quarts daily.

  • Use ACE inhibitors in all patients with heart failure regardless of functional class except in patients with a history of angioedema; use ARBs instead in patients intolerant of ACE inhibitors.

  • Use β-blockers in patients with all NYHA classes of heart failure.

  • Use hydralazine combined with nitrates as an alternative to ACE inhibitors or ARBs in patients intolerant to both, and consider adding it to standard therapy in African-American patients with heart failure.

  • Use low doses of an aldosterone antagonist in patients with NYHA class III to IV heart failure on ACE inhibitors and β-blockers.

  • Use loop diuretics to control volume overload and improve the functional capacity of patients with heart failure.

  • Evaluate patients with heart failure and ventricular arrhythmias, syncope, sudden cardiac death, or EF < 35% for ICD placement.

  • Consider cardiac resynchronization therapy for patients with NYHA class III or IV heart failure, EF <35% and prolonged QRS duration.

  • Treat patients with a normal ejection fraction and signs and symptoms of heart failure for diastolic dysfunction.

DOI: 10.7326/d105
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Author(s) and Disclosures:
Lee R. Goldberg, MD, MPH received honorarium from GlaxoSmithKline, AstraZeneca, Scois, ResMed. Howard J. Eisen, MD is a consultant for Medtronic, Thoratec, Orqis, received honorarium from Medtronic, Boston Scientific, Thoratec, received grants from Medtronic, Boston Scientific, Thoratec, Orquis, St. Jude Medical. John Varras, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.

One or more of the present or past ACP Smart Medicine physician editors worked on this module and had nothing to disclose: Davoren Chick, MD, FACP; Deborah Korenstein, MD, FACP; Marjorie Lazoff, MD; Richard Lynn, MD, FACP.

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