CLINICIAN HEART FAILURE GUIDE · SECTION 2 OF 3
Assess stability, recognize congestion, and act before deterioration.
Severe breathlessness at rest, hypoxemia, pulmonary edema, ongoing chest pain, syncope, or signs of shock require emergency evaluation. Confusion, cold/clammy extremities, and hypotension can suggest poor perfusion.
Activate EMS for an unstable patient. Do not delay transport for outpatient testing or attempt to manage severe decompensation with an oral diuretic adjustment alone.[1], [3]
Compare the patient with their usual baseline, including symptoms, weight, vital signs, and functional capacity.
Weight trends and symptoms help identify worsening congestion. Clear lungs, absent edema, or a single unchanged weight do not reliably exclude heart failure or elevated filling pressures.
Actual medication use, refill access, cost, and the prescribed diuretic plan.
Increased sodium intake or deviation from an individualized fluid plan.
NSAIDs and other drugs that promote fluid retention or impair cardiac function.
Infection, ischemic symptoms, uncontrolled BP, arrhythmia, anemia, or thyroid disease.
Review new prescriptions, over-the-counter products, and recent hospitalizations.[1]
Review the EKG, renal function, electrolytes, and available prior cardiac reports. BNP/NT-proBNP can support the evaluation of unexplained dyspnea but must be interpreted in clinical context. Additional tests depend on suspected causes.
Send the prior EF, study date, valve findings, symptom trajectory, and medication list with the referral. Cardiology can coordinate cardiac imaging, confirm the HF phenotype, and investigate the cause.[1]
Consider pulmonary disease, thromboembolism, renal disease, anemia, and other causes when the presentation or available evidence does not fit heart failure.
For a stable patient with established HF and mild worsening congestion, review the current treatment plan and coordinate with the managing team. Loop diuretics relieve fluid overload; adjustment should account for blood pressure, kidney function, electrolytes, and the response to treatment.
Set a near-term reassessment and arrange laboratory monitoring according to medication changes and clinical risk. Persistent symptoms, inadequate response, worsening renal function, or inability to manage safely as an outpatient should prompt escalation.[4]
New suspected HF or substantial deterioration needs prompt clinical assessment rather than simply adding a diuretic and scheduling a distant follow-up.
Respiratory distress, hypoxemia, acute pulmonary edema, ongoing ischemic symptoms, or poor perfusion/shock.
New/uncertain HF, newly reduced EF, increasing congestion, or persistent symptoms despite treatment.
Stable established HF with a clear treatment, monitoring, and follow-up plan.
Consider advanced HF referral for recurrent admissions, escalating diuretic requirements, refractory symptoms, worsening organ function, or low BP limiting treatment.[4]
Ask patients to track symptoms and daily weight when appropriate, using the same scale and similar conditions. Explain whom to call for new breathlessness, edema, or rapid weight change. Specify individualized thresholds and any diuretic instructions in writing.
Teach emergency symptoms and confirm medication access. A weight trend is a prompt for assessment; patients should not change doses without an agreed plan.[2]
For clinician education. Individualize assessment, treatment, and follow-up with the managing cardiology team.