Therapy » Acute heart failure – An EFIM guideline critical appraisal and adaptation for internists

Acute heart failure – An EFIM guideline critical appraisal and adaptation for internists

DOI: https://dx.doi.org/10.18565/therapy.2024.4.8-25

Kokorin V.A., Gonzalez-Franco A., Cittadini A., Kalejs O., Larina V.N., Marra A.M., Medrano F.J., Monhart Z., Morbidoni L., Pimenta J., Lesniak W.
1) Pirogov Russian National Research Medical University, Moscow, Russian Federation; 2) RUDN University, Moscow, Russian Federation; 3) Hospital Universitario Central de Asturias, Oviedo, Spain; 4) “Federico II” University Hospital and school of medicine, Naples, Italy; 5) Riga Stradins University, Latvian Center of Cardiology, P. Stradins Clinical University hospital, Riga, Latvia; 6) Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany; 7) Instituto de Biomedicina de Sevilla (Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla), Seville, Spain; 8) Universidad de Sevilla, Seville, Spain; 9) Znojmo Hospital, Znojmo, Czech Republic; 10) Masaryk University, Brno, Czech Republic; 11) “Principe di Piemonte” Hospital Senigallia (AN), Italy; 12) Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal; 13) Faculdade de Medicina da Universidade do Porto, Porto, Portugal; 14) Polish Institute for Evidence Based Medicine, Krakow, Poland

Abstract. Several trials have been conducted in the last 2 decades that challenged the management of patients with acute heart failure (AHF) in terms of diagnosis and treatment. Updated international clinical practice guidelines (CPGs) endorsed the evidence from these trials. The aim of this document was to adapt recommendations from existing CPGs to assist physicians in decision making concerning specific and complex scenarios related to AHF.
Methods. The flow for the adaptation procedure was first the identification of unsolved clinical issues in patients with AHF following the PICO (population, intervention, comparison and outcomes) process, then critically appraise the existing CPGs and choose the recommendations, which are most applicable to these specific and complex scenarios.
Results. Seven PICOs were identified and CPGs appraisal was performed. There is no single test able to assist physicians in discriminating patients presenting with acute dyspnea, congestion or hypoxemia. Measurement of natriuretic peptide (NP) and/or cardiac troponin levels on hospital admission is recommended to establish a prognosis in acutely decompensated heart failure, and some other tests may be considered for additive risk stratification. To quantify the degree of congestion in patients with AHF the use of echocardiography and NP is recommended, and chest X-ray and lung ultrasound may be considered. The strategies to manage arterial hypotension and low cardiac output that lead to a more effective resolution of symptoms and a reduction in mortality include short-term, continuous intravenous inotropic support, vasopressor (preferably norepinephrine), renal replacement therapy and temporary mechanical circulatory support. The most updated recommendations on how to treat specifically the patients with AHF and certain comorbidities (diabetes mellitus, COPD, anaemia, kidney dysfunction, and cardiac arrhythmias) are covered. Patients with AHF should generally be discharged from hospital only when their clinical condition is stable, the signs and symptoms of congestion are resolved and the management plan is optimised. The most effective strategies to reduce the readmissions and mortality after discharge are provided. Overall, 51 recommendations were endorsed and the rationale for the selection is reported in the main text.
Conclusion. By the use of proper methodology for the adaptation process, this document offers a simple and updated guide for practising clinicians dealing with AHF patients.

Keywords: critical appraisal, internal medicine, clinical practice guideline, consensus, acute heart failure

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Acute heart failure – An EFIM guideline critical appraisal and adaptation for internists

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