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Canadian Journal of Cardiology

Evidence-Based Management of Acute Heart Failure

Published:January 10, 2021DOI:https://doi.org/10.1016/j.cjca.2021.01.002

      Abstract

      Acute heart failure (AHF) is a complex, heterogeneous, clinical syndrome with high morbidity and mortality, incurring significant health care costs. Patients transition from home to the emergency department, the hospital, and home again and require decisions surrounding diagnosis, treatment, and prognosis at each step of the way. The purpose of this review is to examine the epidemiology, etiology, and classifications of AHF and specifically focus on practical information relevant to the clinician. We examine the mechanisms of decompensation relevant to clinical presentations—including precipitating factors, neuroendocrine interactions, and inflammation—along with how consideration of these factors may help select therapies for an individual patient. The prevalence and significance of end-organ manifestations such as renal, gastrointestinal, respiratory, and neurologic manifestations are discussed. We also highlight how the development of renal dysfunction relates to the choice of a variety of diuretics that may be useful in specific circumstances and review guideline-directed medical therapy. We discuss the practical use (and pitfalls) of a variety of evidence-based clinical scoring criteria available to risk stratify patients with AHF. Finally, evidence-based management of AHF is discussed, including both pharmacologic and nonpharmacologic therapies, including the lack of evidence for using old and new vasodilators and the recent evidence regarding initiation of newer therapies in hospital. Overall, we suggest that clinicians consider implementing the newer data in AHF and subject existing practice patterns and treatments to the same rigour as new therapies.

      Résumé

      L’insuffisance cardiaque aiguë (ICA) est un syndrome clinique hétérogène complexe associé à une morbidité et à une mortalité élevées et à des coûts considérables en matière soins de santé. Les patients passent de leur domicile au service des urgences puis à une chambre d’hôpital pour ensuite revenir à leur domicile, et des décisions quant au diagnostic, au traitement et au pronostic doivent être prises à chacune de ces étapes. Nous présentons ici un compte rendu de l’épidémiologie, de l’étiologie et des classifications de l’ICA, en nous concentrant principalement sur les renseignements pratiques pertinents pour le clinicien. Nous examinons les mécanismes de décompensation pertinents aux manifestations cliniques de l’ICA, y compris les facteurs déclencheurs, les interactions neuroendocriniennes et l’inflammation, ainsi que la façon dont la prise en compte de ces facteurs peut aider au choix des traitements appropriés pour un patient donné. Nous traitons également de la prévalence et de l’importance des manifestations touchant les organes cibles, notamment les manifestations rénales, gastro-intestinales, respiratoires et neurologiques. Nous soulignons comment l’apparition d’une dysfonction rénale est liée au choix de diurétiques qui peuvent se révéler utiles dans des circonstances particulières et présentons les traitements médicaux recommandés dans les lignes directrices. Il est par ailleurs question de l’utilisation pratique (et des écueils) de divers critères d’évaluation clinique fondés sur des données probantes pour stratifier les patients atteints d’ICA en fonction des risques auxquels ils sont exposés. Enfin, nous traitons des stratégies de prise en charge de l’ICA fondées sur des données probantes, y compris les traitements pharmacologiques et non pharmacologiques, ainsi que des lacunes dans les données soutenant l’utilisation d’anciens et de nouveaux vasodilatateurs et des dernières données concernant l’instauration de traitements plus récents en milieu hospitalier. Dans l’ensemble, nous recommandons aux cliniciens de tenir compte des nouvelles données sur le traitement de l’ICA et de faire preuve de la même rigueur à l’égard des pratiques et des traitements actuels qu’à l’égard des nouveaux traitements.
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