Acute Heart Failure Management – Evidence-Based Guidance (JCS Scientific Heart Failure National Protocols Taskforce Session, 2025)
Acute Heart Failure Management – Evidence-Based Guidance
(JCS Scientific Heart Failure National Protocols Taskforce Session, 2025)
Speaker: Dr. Aiman Hamdan, MD, FACC
Keynotes :
1. Initial Stabilization and Diagnostics
• Rapid triage and emergency admission — time-sensitive like ACS.
• Core investigations: ECG, chest X-ray, echocardiography, BNP/NT-proBNP, troponin, renal/electrolyte panels.
• Identify triggers: ischemia, arrhythmia, infection.
• Oxygen therapy as needed → escalate to CPAP/BiPAP or intubation in severe cases.
2. Managing Volume Overload (“Wet” Phenotype)
• IV loop diuretics: first-line; use early and above home dose; monitor renal function.
• If response inadequate (24–48 h) → add thiazide or acetazolamide.
• IV vasodilators (e.g., nitroglycerin, nitroprusside) if SBP ≥ 90 mmHg to reduce filling pressures and dyspnea.
3. Addressing Hypoperfusion (“Cold” States)
• Warm & Dry: optimize long-term therapy, address cause.
• Warm & Wet: diuretics ± vasodilators.
• Cold & Dry (low perfusion, not overloaded): fluid challenge → inotropes → vasopressors if refractory.
• Cold & Wet: stabilize perfusion first, then cautious diuresis ± inotropes; escalate to mechanical support if unresponsive.
(Flowchart illustrated on p. 2)
4. Add-On and Device-Based Therapies
• Persistent symptoms despite GDMT:
• Replace ACEi/ARB → ARNi.
• Add Ivabradine if HR ≥ 70 bpm in sinus rhythm on max beta-blocker.
• Device options:
• ICD if LVEF ≤ 35 % + life expectancy > 1 yr.
• CRT for LBBB/wide QRS.
• LVAD or advanced mechanical support in Stage D / refractory HF.
5. Ongoing In-Hospital Care
• VTE prophylaxis for immobilized patients
(IMPROVE-VTE Score:
Assesses VTE risk — heart/respiratory failure, cancer, immobility > 7 days, prior VTE, age ≥ 60, high D-dimer.
→ ≥ 4 points = high risk → give prophylaxis (LMWH 40 mg SC daily or UFH 5000 U SC q8–12 h).
Validated internationally —including AHA/ACC and APSC–Japan (2024 updates), which confirmed its usefulness and suggested minor recalibration for Asian populations due to lower baseline VTE rates.
Developed from the U.S. IMPROVE Registry (Spyropoulos AC et al., Thromb Haemost 2016; 116: 352–362 – AHA/ACC and APSC–Japan 2024 updates on validation and regional adaptation).
IMPROVE-Bleed Score:
Assesses bleeding risk — prior bleed, thrombocytopenia, severe renal/liver failure, active cancer, age ≥ 85.
→ ≥ 7 points = high bleeding risk → avoid or shorten prophylaxis.
Use both to balance clot vs. bleed risk (IMPROVE-VTE ≥ 4 and IMPROVE-Bleed < 7).
Routine long-term prophylaxis after discharge is not recommended unless immobility or very high risk persists.
Recommended drugs: LMWH or UFH during hospitalization; short-course oral DOACs (e.g., rivaroxaban 10 mg daily) may be considered post-discharge in selected high-risk, low-bleed patients.)
• Restart/initiate guideline-directed medical therapies (GDMT) once stable:
SGLT2 inhibitors, MRAs, ARNi/ACEi/ARB, beta-blockers.
SGLT2i and MRAs can be started early due to minimal blood-pressure effect.
6. Pre-Discharge and Transition Strategy
• Ensure complete decongestion and stable body weight.
• Adjust home diuretic dose, monitor electrolytes/renal function.
• Plan rehabilitation and post-discharge uptitration of chronic HF therapy.
7. Monitoring and Long-Term Follow-up
• Regular review of symptoms, labs, and biomarkers.
• Patient education: self-care, daily weights, early symptom recognition.
• Telemonitoring and remote follow-up reduce readmissions.
8. Comorbidities and Special Populations
• Diabetes → emphasize SGLT2i and glucose control.
• Renal impairment → adjust medication doses, monitor closely.
• Atrial fibrillation, anemia, iron deficiency → correct as needed.
9. 9. Prognosis and Risk Stratification
• Use clinical risk scores (e.g., MAGGIC) and biomarkers for outcome prediction.
• Incorporate imaging parameters (echo indices) into overall risk assessment.
(Additional note – MAGGIC Score)
The MAGGIC (Meta-Analysis Global Group in Chronic Heart Failure) score is a validated international tool that predicts 1- and 3-year mortality risk in heart-failure patients.
It integrates key variables — age, LVEF, NYHA class, systolic BP, creatinine, diabetes, smoking, BMI, medications, and etiology — to generate a simple risk estimate.
→ Higher score = higher predicted mortality.
When combined with biomarkers (NT-proBNP, troponin) and echocardiographic measures (LVEF, LV size, strain), it provides a more comprehensive and accurate risk profile for clinical decision-making.
Key Takeaway:
Early recognition, structured hemodynamic profiling (“warm / cold, wet / dry”), and rapid initiation of guideline-directed therapies are the pillars of improving survival and reducing rehospitalization in acute heart failure.