Guidelines on the management of acute heart failure in the elderly (executive summary)

Heart failure is an increasing reason for hospitalization and the leading cause of death in patients with adult congenital heart disease (ACHD). Recently, the European Society of Cardiology and the American Heart Association published consensus documents on the management of chronic heart failure in ACHD patients. However, little data and/or guidelines are available for the management of (sub)acute heart failure. The ACHD population is heterogeneous by definition and often has complex underlying anatomy, which could pose a challenge to the physician confronted with the ACHD patient in (sub)acute heart failure. Recognizing the underlying anatomy and awareness of the possible complications related would result in better treatment, avoid unnecessary delays, and improve outcomes of the ACHD patient with (sub)acute heart failure. This review focuses on the management of (sub)acute heart failure in ACHD with specific attention to lesion-specific issues.

Temporal trends in the outcomes of acute heart failure: between consolatory evidences and real progress.

Admissions to hospital for acute decompensated heart failure continue to increase and represent a significant burden on both patients' and healthcare resources. The majority of these admissions are for the control of volume overload; however, standard treatment with intravenous diuretics is not always effective and can lead to increased renal morbidity. One alternative to standard therapy is mechanical fluid removal with ultrafiltration, this review will highlight the current evidence and efficacy regarding ultrafiltration use in acute heart failure. Multiple recent clinical trials have demonstrated the safety and feasibility of ultrafiltration in the management of acute heart failure. Ultrafiltration may be more effective at removing fluid than standard diuretic therapy and has been associated with beneficial long-term results. However, it remains to be determined whether ultrafiltration is truly nephroprotective and when and how this therapy is best utilized. Ultrafiltration is an attractive alternative to standard diuretic therapy in the management of volume overload from acute heart failure. Further research is needed to confirm the cost-effectiveness and to determine long-term impacts on morbidity and mortality.

Background:The emergency department (ED) has a pivotal influence on the management of acute heart failure (AHF), but data concerning current ED management are scarce. This Beijing AHF Registry Study investigated the characteristics, ED management, and short- and long-term clinical outcomes of AHF.Methods:This prospective, multicenter, observational study consecutively enrolled 3335 AHF patients who visited 14 EDs in Beijing from January 1, 2011, to September 23, 2012. Baseline data on characteristics and management were collected in the EDs. Follow-up data on death and readmissions were collected until November 31, 2013, with a response rate of 92.80%. The data were reported as median (interquartile range) for the continuous variables, or as number (percentage) for the categorical variables.Results:The median age of the enrolled patients was 71 (58–79) years, and 46.84% were women. In patients with AHF, coronary heart disease (43.27%) was the most common etiology, and myocardium ischemia (30.22%) was the main precipitant. Most of the patients in the ED received intravenous treatments, including diuretics (79.28%) and vasodilators (74.90%). Fewer patients in the ED received neurohormonal antagonists, and 25.94%, 31.12%, and 33.73% of patients received angiotensin converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, and spironolactone, respectively. The proportions of patients who were admitted, discharged, left against medical advice, and died were 55.53%, 33.58%, 7.08%, and 3.81%, respectively. All-cause mortalities at 30 days and 1 year were 15.30% and 32.27%, respectively.Conclusions:Substantial details on characteristics and ED management of AHF were investigated. The clinical outcomes of AHF patients were dismal. Thus, further investigations of ED-based therapeutic approaches for AHF are needed.

Acute decompensated heart failure is the leading cause of hospitalization in older adults, and more than half of all patients admitted with this condition are over 75 years of age. In addition, hospital mortality is threefold higher in patients over 75 years of age compared with younger patients. This article reviews the pathophysiology, clinical features and management of acute heart failure in older adults, highlighting recent advances in the field. It is anticipated that over the next 5-10 years, new approaches to the treatment of acute decompensated heart failure will become available. Nonetheless, additional research is required to develop more effective strategies for the prevention and management of both acute and chronic heart failure in our rapidly growing elderly population.

Background/Introduction Current guidelines recommend targeting overall decongestion in management of patients with decompensated heart failure. With lower extremity edema among the most prevalent symptoms in patients admitted with decompensation, this often serves as a clinical target. Lower extremity compression wraps (LECW) are seldom used in the acute setting, with little data on efficacy in heart failure, despite serving as a cornerstone of chronic lymphedema management. Purpose Evaluate the efficacy of LECW as adjuvant therapy in management of HF with reduced ejection fraction (EF). Methods Open-label, randomized, parallel group controlled trial, with 2:1 randomization of adult patients with a history of HF and reduced EF less than 40% admitted to telemetry unit for intravenous (IV) diuretic therapy. Results A total of 32 patients were enrolled, with 29 patients completing the study; 19 (66%) in the control arm, and 10 (34%) in the intervention arm. There were no significant differences in baseline characteristics of the two groups. Patients in the intervention arm required less escalation of diuretic therapy (0 vs 5 patients, p=0.079), and less frequent use of continuous infusion therapy (0 vs 7 patients, p=0.027). Total days of IV diuresis was not significantly different between the two groups. Greater net reduction of edema was seen in the intervention group (1.5+ [1–2] vs 1+ [1–2], p=0.072), with fewer cases of acute kidney injury (1 vs 13, p=0.005). The intervention group scored significantly better on MLWHF (55.5 vs 65, p=0.021), including both the physical (17.5 vs 23, p<0.001) and emotional (5.5 vs 11, p<0.001) dimension scores. Overall LOS was shorter in the intervention group (3.5 [3–7] vs 6 [5–10] days, p=0.05). A Poisson regression model was used to examine the effect of intervention on LOS (IRR=0.62, 95% CI 0.44–0.86, p=0.005), suggesting an overall 38% shorter LOS. Conclusion In this open-label parallel group RCT, use of LECW resulted in less IV diuretic continuous infusion therapy, greater net reduction in lower extremity edema, reduced patient assessed HF burden, and shorter hospital LOS, with fewer rates of AKI. Trends toward fewer total days of IV diuresis, less escalation of diuresis, and greater reduction in edema were also observed. Larger scale clinical trials are needed to further establish LECW as efficacious adjuvant therapy in the management of acute heart failure. Funding Acknowledgement Type of funding sources: None.

Congestive heart failure has emerged as an important public health problem in the United States and is pres ently the number one Diagnostic Related Group for inpatients over the age of 65. Patients admitted to an intensive care or coronary care unit because of de compensated heart failure are frequently older and frequently have multiple serious medical problems. In addition to standard intensive care practices, it is often important to characterize systolic and diastolic proper ties qualitatively with echocardiography. Hemodynamic monitoring is essential for patients with hypotension, oliguria, or questionable left ventricular filling pressures. A combination of loop diuretics, intravenous vaso dilators, and inotropic agents will often be necessary to correct severe underlying hemodynamic abnormalities, and an understanding of basic left ventricular systolic and diastolic function is essential to the optimal use of these potent agents. Manipulation of loading conditions and contractile state are important considerations, and pharmacological interventions should be targeted to ward specific abnormalities in individual patients. Once patients are stabilized, switching to orally active inotro pic and vasodilator agents can usually be accomplished over a 24-hour period, allowing for a total stay of 48 to 72 hours in the intensive care unit. Congestive heart failure (CHF) is rapidly becoming a public health problem of major proportions [1- 5]. As the American population continues to age, we can expect greater numbers of patients to be admitted to intensive care units (ICUs) and coro nary care units (CCUs) with progressive decompen sation of previously stable CHF. Our current ap proaches to the diagnosis and management of acute heart failure are summarized; however, the care of such patients must always be highly individualized.

079 Management of acute heart failure in 2009: the OFICA study

Worldwide, valvular heart disease (VHD) is a common cause of hospitalization for acute heart failure. In acute heart failure caused by VHD, symptoms result from rapid haemodynamic changes and subsequent decline in cardiac function, and if left untreated, leads to acute decompensation and cardiogenic shock. Current evidence remains scarce and recommendations regarding the management of acute heart failure caused by VHD are lacking in most recent international guidelines. Herein, we review the management of acute heart failure caused by VHD with a focus on transcatheter therapies and describe currently available evidence based on a systematic literature search on the following valve pathologies: (i) aortic stenosis, (ii) aortic regurgitation, (iii) mitral regurgitation, and (iv) mitral stenosis. Articles reporting outcomes following urgent or emergent valve intervention in the setting of cardiogenic shock or acute heart failure were considered. After screening a total of 2234 articles, 76 published between 1994 and 2023 were included in subsequent analysis. Based on available evidence, proposed treatment algorithms to guide optimal management of acute heart failure caused by VHD were created. As the number of patients presenting with acute heart failure caused by VHD continues to rise and outcomes following transcatheter valve interventions continue to improve, it is inevitable that minimally invasive options will play an increasingly important role in the acute setting, especially given these patients are at an increased operative risk. This review aims to present an organized approach to the complex management and interventional treatment of patients with acute heart failure caused by VHD.

Acute heart failure is still characterized by poor prognosis with high mortality. Diagnosis is based on clinical symptoms and hemodynamic measurements. Early coronary revascularization in cardiogenic shock complicating myocardial infarction improves outcome. The further contemporary therapeutic options in the management of acute heart failure are limited to a merely symptomatic effect with relief of dyspnea, reduction of volume overload and improvement of hemodynamic parameters by vasodilators (in hypertension) or inotropic and vasopressor agents (in hypotension). However, so far no medical therapy has been shown to positively affect clinical outcomes of patients with acute heart failure. Early identification of impending circulatory collapse coupled with rapid implementation of mechanical circulatory support may contribute to mortality reduction as a combined concept of the management of acute heart failure.

The Complex Relationship Between Ischemic Heart Disease and COPD Exacerbations

The prevalence of heart failure (HF) is on the rise due to the aging of society. Furthermore, the continuous progress and widespread adoption of screening and diagnostic strategies have led to an increase in the detection rate of HF, effectively increasing the number of patients requiring monitoring and treatment. Because HF is associated with substantial rates of mortality and morbidity, as well as high socioeconomic burden, there is an increasing need for developing specific guidelines for HF management. The Korean guidelines for the diagnosis and management of chronic heart failure (CHF) were introduced in March 2016. However, CHF and acute heart failure (AHF) represent distinct disease entities. Here, we introduce the Korean guidelines for the management of AHF with reduced or preserved ejection fraction. Part III of this guideline covers management strategies optimized according to the etiology of AHF and the presence of co-morbidities.

International Society for Heart and Lung Transplantation: Practice guidelines for management of heart failure in children

Background: Milrinone, a phosphodiesterase-III inhibitor, remains a commonly used inotropic agent in the management of acute heart failure (AHF), particularly in scenarios characterized by low cardiac output, end-organ hypoperfusion, or cardiogenic shock. Despite decades of clinical use, the evidence regarding its comparative effectiveness, hemodynamic benefits, and safety profile continues to evolve. Recent randomized trials, observational cohorts, meta-analyses, and contemporary heart failure guidelines provide updated insights into the clinical utility of milrinone in AHF. Objective: To systematically review and synthesize the current evidence on milrinone therapy in acute heart failure, focusing on: (1) clinical outcomes; (2) hemodynamic effects; and (3) safety considerations. Methods: A systematic evaluation of selected literature—including randomized controlled trials (e.g., OPTIME-CHF; DOREMI), meta-analyses, guideline recommendations (AHA/ACC/HFSA 2022; ESC 2021–2023), and contemporary reviews—was performed. Studies examining milrinone use in acute heart failure, acute decompensated heart failure, and cardiogenic shock were included. Data related to mortality, rehospitalization, hemodynamic response, adverse effects, and comparative performance against dobutamine were summarized narratively. Results: Evidence from comparative trials demonstrates that milrinone improves cardiac index and reduces pulmonary pressures, supporting its role in patients with low-output AHF. However, clinical outcomes such as mortality and rehospitalization show no consistent superiority over dobutamine, with some observational studies suggesting potential benefits in selected subgroups of acute decompensated heart failure. Meta-analyses remain heterogeneous, reflecting differences in study design and patient population. Safety findings indicate increased risk of arrhythmias and hypotension, particularly in patients with renal dysfunction or advanced shock. Guidelines recommend milrinone as an option for patients with preserved blood pressure, on chronic beta-blocker therapy, or requiring pulmonary vasodilation. Conclusions: Milrinone provides meaningful hemodynamic improvement in AHF and may offer clinical advantages in specific patient scenarios. Nevertheless, its overall impact on major clinical outcomes remains uncertain, and safety concerns persist. Individualized therapy guided by patient profile, hemodynamic status, and guideline recommendations is essential. Further high-quality trials are needed to clarify its optimal role in the modern management of acute heart failure.

This review will provide an overview of recent advances in the management of acute decompensated heart failure, focusing on major publications from the past few years. There have been several publications investigating different strategies in the management of acute decompensated heart failure. Trials have investigated the role of ultrafiltration, diuretic infusions and recombinant B-type natriuretic peptide for the treatment of these patients. In patients with acute decompensated heart failure, the use of ultrafiltration in place of diuretics, diuretic infusions, and B-type natriuretic peptide has not shown benefit in recent trials. Unfortunately, there have been no major advances in the management of patients with acute decompensated heart failure.