Heart Failure

2022 AHA/ACC/HFSA Heart Failure Guideline

Cardiac & EKG

Types by ejection fraction (EF)

HFrEF (reduced)	EF ≤40%
HFmrEF (mildly reduced)	EF 41–49%
HFpEF (preserved)	EF ≥50%
HFimpEF (improved)	Was ≤40%, now >40%

BNP >100 pg/mL or NT-proBNP >300 pg/mL supports HF; levels fall as HF improves. Normal EF is ~50–70%.

Left-sided vs. right-sided

Left: backs up into the Lungs

Dyspnea, orthopnea, PND
Crackles, cough, pink frothy sputum
S3 gallop, tachycardia
Fatigue, confusion, ↓ urine output

Right: backs up into the Rest of the body

JVD
Dependent edema, weight gain
Hepatomegaly, ascites
Anorexia, nausea

The most common cause of right-sided HF is left-sided HF.

HFrEF: the four core drug classes Updated

Class	Examples	Nursing points
ARNI (preferred) or ACEi/ARB	sacubitril/valsartan; lisinopril; losartan	Hypotension, ↑K⁺, renal function. 36-hour gap when switching from an ACE inhibitor to an ARNI (angioedema risk).
Evidence-based beta blocker	carvedilol, metoprolol succinate, bisoprolol	Start low, go slow; may feel more tired at first. Hold for symptomatic bradycardia or hypotension.
Mineralocorticoid receptor antagonist (MRA)	spironolactone, eplerenone	Check K⁺ and creatinine; avoid potassium supplements and salt substitutes.
SGLT2 inhibitor	dapagliflozin, empagliflozin	Benefit with or without diabetes. Genital infections, volume depletion, rare euglycemic DKA; usually held ~3 days before surgery.

Loop diuretics (furosemide) relieve congestion and symptoms but don't prolong life. For HFpEF, SGLT2 inhibitors and diuretics are the mainstay.

Acute decompensated HF

High Fowler's; oxygen to keep SpO₂ ≥90% (non-invasive ventilation if needed).
IV loop diuretic; monitor urine output, K⁺, Mg²⁺, creatinine, BP.
Vasodilators (nitroglycerin) if BP allows.
Strict I&O, daily weight, lung sounds.
Avoid: NSAIDs, diltiazem/verapamil (in HFrEF), thiazolidinediones (pioglitazone).

Teaching for home

Weigh daily: same time, same scale, after voiding, before breakfast, similar clothing.
Report a gain of >1 kg (2–3 lb) in a day or 2 kg (5 lb) in a week, or worse breathlessness, swelling, or needing more pillows.
Limit sodium (commonly <2–3 g/day); fluid limits only if ordered.
Take meds even when feeling well; check BP/pulse as taught.
Stay active (cardiac rehab); flu, COVID and pneumococcal vaccines.

Digoxin

Check the apical pulse for 1 full minute first; hold and notify if <60/min (adults) or as ordered. Therapeutic level 0.5–2.0 ng/mL (0.5–0.9 is the target in HF). Toxicity: anorexia, nausea, vomiting, visual changes (yellow-green halos), bradycardia, dysrhythmias. Hypokalemia increases toxicity. Antidote: digoxin immune fab.

Memory hook Left = Lungs. Right = Rest of the body.

Classes I–IV (NYHA) describe symptoms and can go up and down. Stages A–D (ACC/AHA) describe progression and only move forward.