managing heart failure

Heart failure is a major public health prob-lem in the United States, and it continues tobe the leading cause of hospitalization inpeople over age 65. Unfortunately, theprognosis for this condition isn’t positive:50% of patients with heart failure over a 4-year period will die of the disease. Morethan 287,000 people die yearly of heart fail-ure, and 40% of patients admitted to thehospital with the condition die or are read-mitted within 1 year. Not to mention thatthe estimated annual cost for the manage-ment of heart failure in 2006 was $29.6 bil-lion dollars.

In this article, I’ll help you understand thepathophysiology, causes, and signs andsymptoms of heart failure; important diag-nostic tools and treatment options; andpatient-teaching strategies to help yourpatient manage his condition.

Back to basicsThe basic definition of heart failure, for-merly known as congestive heart failure, isthe heart’s inability to pump enough bloodto meet the body’s oxygen and nutrientdemands. Heart failure can be systolic ordiastolic, left or right sided, and acute orchronic. As a nurse, you’re likely to take

care of patients who are experiencing anacute exacerbation of heart failure in thehospital and those who are managingchronic heart failure in the outpatient set-ting.

Let’s take a closer look at the categories ofheart failure: • systolic heart failure (pumping prob-lem)—the inability of the heart to contractenough to provide blood flow forward• diastolic heart failure (filling problem)—the inability of the left ventricle to relax nor-mally, resulting in fluid backing up into thelungs • left-sided heart failure—the inability ofthe left ventricle to pump enough blood,causing fluid to back up into the lungs• right-sided heart failure—the inefficientpumping of the right side of the heart, caus-ing congestion or fluid buildup in the ab-domen, legs, and feet • acute heart failure—an emergency situa-tion in which a patient who was completelyasymptomatic before the onset of heart fail-ure decompensates when there’s an acuteinjury to the heart, such as a myocardial in-farction (MI), impairing its ability to func-tion• chronic heart failure—a long-term syn-

12 Nursing made Incredibly Easy! May/June 2009

More than 5 million Americans are living with heart failure and 500,000 moreare diagnosed each year, according to the American Heart Association. That’swhy it’s important for you to understand the disease process and the availabletreatment options. We give you the lowdown so you can provide the best carepossible for this growing patient population.By Lacey Buckler, RN, ACNP-BC, MSN Acute Care Nurse Practitioner • Inpatient Cardiology • Gill Heart Institute • University of Kentucky • Lexington, Ky.

The author has disclosed that she has no significant relationships with or financial interest in any commercial companies that pertain to this educational activity.

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Managing heart failure

drome in which the patient experiences per-sistent signs and symptoms over an ex-tended period of time, likely as a result of apreexisting cardiac condition.

Cause and effect There are a variety of conditions that canlead to the development of heart failure;however, the progressive process that oc-curs in response to one of these initiatingevents is similar. These conditions include: • coronary artery disease. Atherosclerosisof the coronary arteries is the primarycause of heart failure; it’s found in morethan 60% of patients with the condition.Hypoxia and acidosis lead to ischemia,which causes an MI that leads to heartmuscle necrosis, myocardial cell death, andloss of contractility. The extent of the MIcorrelates with the severity of the heartfailure.• cardiomyopathy. A disease of the my-ocardium, there are three types of car-diomyopathy: dilated, hypertrophic, andrestrictive (see Picturing dilated cardiomyopa-thy). The most common type, dilated car-diomyopathy may result from an un-known cause (idiopathic), an inflammatoryprocess such as myocarditis, or alcoholabuse; it causes diffuse cellular necrosisand fibrosis, leading to decreased contrac-tility (systolic failure). Hypertrophic andrestrictive cardiomyopathy lead to de-creased distensibility and ventricular filling(diastolic failure). Heart failure due to car-diomyopathy usually becomes chronic andprogressive; however, both may resolve ifthe cause, such as alcohol use, is removed.• hypertension. Systemic or pulmonary hy-pertension increases the heart’s workload,leading to hypertrophy of its muscle fibers.

May/June 2009 Nursing made Incredibly Easy! 13

t failure

This hypertrophy may impair the heart’sability to fill properly during diastole, andthe hypertrophied ventricle may eventu-ally fail (see Picturing left ventricular hyper-trophy).• valvular heart disease. The valves ensurethat blood flows in one direction. In valvu-lar disorders, blood has an increasing diffi-

culty moving forward, increasing pressurewithin the heart and cardiac workload andleading to heart failure. Degenerative aorticstenosis and chronic aortic and mitral regur-gitation are often the culprits.

Other conditions that may contribute tothe development and severity of heart failureinclude:


Picturing dilated cardiomyopathyDilated cardiomyopathy primarily affects systolic function. Here’s what happens:

Secondary increasedatrial chamber size

Increased ventricularchamber size

(dilation)

Decreased musclesize, but increased

heart size

Cardiacmuscle fibersare extensivelydamaged.

Early changesof heart failure(increasedheart rate andleft ventricularhypertrophy)help the heartto compensatefunctionally.

Thecompensatorymechanismseventually areunable tomaintainadequatecardiac output.

Severe leftventriculardilation occursas venousreturn andsystemicvascularresistanceincrease.

Eventually, allchambers maydilate, causinggeneralizedcardiomegalywith associatedrisk of arrhyth-mias andemboli.

Contractility in the leftventricledecreases,lowering strokevolume.

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The pathophysiology steps

• increased metabolic rate• iron overload• hypoxia• severe anemia• electrolyte abnormalities• cardiac dysrhythmias• diabetes.

Signs and symptomsafootOften, signs and symptoms ofheart failure are the key to earlydetection because they lead a pa-tient to seek medical attention.

Signs and symptoms of left-sided heart failure are related topulmonary congestion andinclude:• dyspnea• unexplained cough• pulmonary crackles• low oxygen saturation levels• third heart sound (S3)• reduced urine output• altered digestion• dizziness and light-headedness• confusion• restlessness and anxiety• fatigue and weakness.

Signs and symptoms of right-sided heartfailure include:• lower extremity edema • enlargement of the liver• ascites (accumulation of fluid in the peri-toneal cavity)• anorexia• abdominal pain• nausea• weight gain• weakness.

Diagnostically speakingWhen a patient presents with symptoms ofheart failure, there’s an initial set of assess-ments, lab studies, and diagnostic tests thatmust be done in order to confirm the diag-nosis.

The most important piece of the patient

assessment is the initial medical history andphysical exam. The nurse is often the firstperson to obtain data from the patient abouthis history. It’s important to gather informa-tion regarding the patient’s risk profile, his-tory of cardiac events, and response to previ-ous therapies if this isn’t a new diagnosis.There are also many questions you can askto elicit important clinical data to help thehealthcare provider determine the cause andseverity of heart failure and the treatmentplan for the patient. See Assessment questionsfor heart failure for a list of questions devel-oped by the American Association of HeartFailure Nurses that can help you completethe initial assessment.

Specific blood tests will be ordered to helpdetermine the patient’s diagnosis. One of themost specific for heart failure is the measure-ment of brain natriuretic peptide (BNP), ahormone secreted by the heart at high levels


Picturing left ventricular hypertrophyHypertrophy of the left ventricle is one of the heart’s first steps to compensate foreither increased pressures or increased blood volume.

Increasedcardiac output

Thickened leftventricular wall

Small leftventricularcavity

Thickenedseptal wall

when it’s injured or overworked. See“Deciphering BNP” in this issue formore information about BNP as a diag-nostic tool. Lab tests include a complete

blood cell count, complete metabolicpanel (electrolytes, creatinine, glucose,

and liver function studies), and urinaly-sis. Other lab tests that may be ordered todetermine the cause of heart failure include

thyroid function tests, a fasting lipid profile,and testing for offending drug levels.

One of the most important diagnostictools for heart failure is the echocardio-gram, or echo. Not only is this an impor-tant assessment tool when the patient pre-sents for the first time with heart failure,but it can also provide information periodi-cally on the improvement of his heart’s


I failed? I demanda retest!

Assessment questions for heart failureSymptoms• What symptoms prompted you to seek medical care? Whendid they begin?• Did your symptoms begin suddenly or gradually worsenover time?• What makes the symptoms better or worse?• Do the symptoms occur continuously or only with certainactivities?• Do symptoms improve with rest?• Do you have any pain now? Did you recently have pain?Rate it on a 0-to-10 scale.• Has your heartbeat felt any different than usual, such as rac-ing, fluttering, or skipping?Breathing• Have you felt short of breath? Do you wake up short ofbreath at night?• Can you speak as much as you like before getting short ofbreath?• What makes your breathing easier?• Do you cough? Is it worse than usual?• Do you cough throughout the day or mostly in the morning?• Do you cough up any secretions?• Do you use oxygen at home?Sleep• Have symptoms kept you from sleeping?• Do you sleep in bed or in a chair?• Are you able to lie flat in bed?• How many pillows do you use to sleep? Is this more or lessthan usual?• Have you recently slept more or less than usual? Do youfeel rested?• Does your spouse or significant other tell you that you snoreor intermittently stop breathing during sleep?Diet• Have you recently eaten more salty foods or drank morewater than usual?• How often do you eat out?

• How often do you weigh yourself?• Have you gained or lost weight recently?• Have you experienced any swelling? Is swelling present allday or only evenings?• Have you felt bloated or had edema?• How far up your legs do you have edema?• Are your clothes, belt, rings, and shoes tighter than 1 weekor 1 month ago?• Have you had nausea or abdominal pain?Medications• Have you taken all prescribed medications?• Did you run out of any medications?• Have you had diarrhea or vomiting that may have affectedabsorption of medications?• Have you taken extra diuretic medications?• Have you changed the dose of any medication?• Did any physician or nurse practitioner recently prescribedifferent medications for you or change the dose of your med-ications?• Do you take any over-the-counter medications or herbalsupplements?Activity• How far can you walk?• Can you dress, bathe, prepare food, and climb stairs with-out stopping to rest?• What activities could you do recently but not now becauseof worsened symptoms?• Have you decreased your activity level?Other• Do you have difficulty remembering information or do youhave feelings of confusion?• Have you had other health problems that may make yourheart failure worse?

Source: American Association of Heart Failure Nurses. ComprehensiveAssessment and Symptoms of Heart Failure—CASH. http://aahfn.org/assets/Comprehensive_Assessment_and_Symptoms_of_HF-CASH.pdf.

function. Echocardiography is a type ofcardiac ultrasound that involves pulsedand continuous Doppler waves. An echoprovides an accurate assessment of leftventricular function while also determiningwhether a patient has systolic or diastolicdysfunction. The number most frequentlyquoted from the echo is the ejection frac-tion (EF). EF is the measurement of howeffectively the heart is pumping blood. Anormal EF is greater than 55%. That meanswith every cardiac cycle more than 55% ofthe blood is being pumped out of the ven-tricle.

Anticipate an order for a chest X-ray toevaluate the size of the patient’s heart andthe basic heart structures and to determinethe amount of fluid buildup in his lungfields. An ECG should also be ordered toexamine the electrical activity of the heart.Other diagnostic modalities that may beordered include a cardiac stress test, cardiaccatheterization (angiogram), a cardiac com-puted tomography scan or magnetic reso-nance imaging, radionuclide ventriculogra-phy, ambulatory ECG monitoring (Holtermonitor), pulmonary function tests, a heartbiopsy, and exercise testing such as the 6-minute walk.

After all the data are obtained, the health-care provider can then determine the causeand classification of the patient’s heart failureand the appropriate treatment plan. There aretwo well-accepted classification systems usedto describe heart failure, focusing on eitherstructural abnormalities or symptoms: theAmerican College of Cardiology/AmericanHeart Association stages of heart failure andthe New York Heart Association (NYHA)functional classifications (see Managing thestages of heart failure).

Treatments 1, 2, 3 The Institute for Healthcare Improvementrecommends the following bundle, or com-ponents of care, for all patients with heartfailure unless contraindicated or the patientcan’t tolerate them:


Managing the stages of heart failureThe American College of Cardiology/American Heart Association 2005 guide-line update classifies heart failure into four stages and makes specific recom-mendations for each.

Stage A identifies patients at high risk for heart failure because of condi-tions such as hypertension, diabetes, and obesity.• Treat each comorbidity according to current evidence-based guidelines.

Stage B includes patients with structural heart disease, such as left ven-tricular remodeling, left ventricular hypertrophy, or previous MI, but no symp-toms.• Provide all appropriate therapies in Stage A.• Focus on slowing the progression of ventricular remodeling and delayingthe onset of heart failure symptoms.• Strongly recommended in appropriate patients: Treat with ACE inhibitors orbeta-blockers unless contraindicated; these drugs delay the onset of symp-toms and decrease the risk of death and hospitalization.

Stage C includes patients with past or current heart failure symptomsassociated with structural heart disease such as advanced ventricular remod-eling.• Use appropriate treatments for Stages A and B.• Modify fluid and dietary intake.• Use additional drug therapies, such as diuretics, aldosterone inhibitors, andARBs in patients who can’t tolerate ACE inhibitors, digoxin, and vasodilators.• Treat with nonpharmacologic measures such as biventricular pacing, anICD, and valve or revascularization surgery.• Avoid drugs known to cause adverse reactions in symptomatic patients,including nonsteroidal anti-inflammatory drugs, most antiarrhythmics, andcalcium channel blockers.• Administer anticoagulation therapy to patients with a history of previousembolic event, paroxysmal or persistent atrial fibrillation, familial dilated car-diomyopathy, and underlying disorders that may increase the risk of throm-boembolism.

Stage D includes patients with refractory advanced heart failure havingsymptoms at rest or with minimal exertion and frequently requiring interven-tion in the acute setting because of clinical deterioration.• Improve cardiac performance.• Facilitate diuresis.• Promote clinical stability.

Achieving these goals may require I.V. diuretics, inotropic support (milri-none, dobutamine, or dopamine), or vasodilators (nitroprusside, nitroglycerin,or nesiritide). As heart failure progresses, many patients can no longer toler-ate ACE inhibitors and beta-blockers due to renal dysfunction and hypoten-sion and may need supportive therapy to sustain life (a left ventricular assistdevice, continuous I.V. inotropic therapy, experimental surgery or drugs, or aheart transplant) or end-of-life or hospice care.

Source: Hunt SA, American College of Cardiology, American Heart Association TaskForce on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for theEvaluation and Management of Heart Failure). ACC/AHA 2005 guideline update for thediagnosis and management of chronic heart failure in the adult: a report of the AmericanCollege of Cardiology/American Heart Association Task Force on Practice Guidelines(Writing Committee to Update the 2001 Guidelines for the Evaluation and Managementof Heart Failure). J Am Coll Cardiol. 2005;46(6):e1-e82.

• assessment of left ventricular systolicfunction• an angiotensin-converting enzyme (ACE)inhibitor or angiotensin receptor blocker(ARB) at discharge when left ventricular EFis less than 40%, indicating systolic dysfunc-tion• an anticoagulant at discharge if the pa-tient has chronic or recurrent atrial fibrilla-tion• smoking cessation counseling• discharge instructions addressing activity,diet, medications, follow-up appointments,

weight monitoring, and whatto do if symptoms worsen• seasonal influenza immu-

nization• pneumococcal immunization

• optional beta-blocker therapy atdischarge for stabilized patients with

left ventricular systolic dysfunction with-out contraindications.

The treatment of heart failure can be fur-ther categorized into three basic strategies:pharmacologic management, devices andsurgical management, and lifestyle manage-ment. All three are very important whencombined and provide the best prognosis forthe patient. Let’s break it down.

Pharmacologic Several drugs may be used for the medicalmanagement of heart failure, includingACE inhibitors, beta-blockers, and aldos-terone antagonists.

The foundation of heart failure treatmentis the ACE inhibitor. Unless it’s contraindi-cated, every patient with an EF of less than40% should receive an ACE inhibitor, whichhas been shown to improve ventricular func-tion and patient well-being, reduce hospital-ization, and increase survival. If the patientis intolerant to an ACE inhibitor, an ARBshould be initiated.

Another class of drugs that’s important forthe patient with heart failure is beta-block-ers. Unless contraindicated or not tolerated,a beta-blocker should be started for everyheart failure patient with an EF of less than40% due to the mortality benefit as shown inmany randomized controlled trials.

An aldosterone antagonist may be addedto the patient’s pharmacologic therapy if hisEF is less than 35% and he’s on adequateACE inhibitor therapy. Unlike the first twocategories of drugs, aldosterone antagonistsare approved for NYHA Classes III and IVand must be used cautiously, acknowledg-ing renal function and potassium level.These drugs have been shown to decreasehospital admissions for heart failure and alsoincrease survival when added to existingtherapy.

Other drugs that may be used in heartfailure management include hydralazine/isorbide, diuretics, and digoxin. Hydralazine/isosorbide may be added as an alternative toan ACE inhibitor or ARB if the patient isintolerant to both drugs or it may be addedto existing therapy if symptoms continue toprogress. Diuretics are used as symptomrelief agents and are recommended forpatients who have clinical signs of conges-tion. Digoxin can be used in patients withheart failure and atrial fibrillation to slowconduction through the atrioventricularnode, which increases left ventricular func-tion and results in increased diuresis, andto increase the force of myocardial contrac-tion. It may also be added to existing thera-py for a patient with NYHA Class II, III, orIV heart failure and an EF of less than 40%who’s receiving optimal doses of an ACE


Ejectionfraction lessthan 40% =

ACE inhibitor.

Drugs commonlyused to treatheart failure• ACE inhibitors: captopril, enalapril,lisinopril, ramipril, and trandolapril• ARBs: candesartan and valsartan• Aldosterone antagonists: eplerenoneand spironolactone• Beta-blockers: bisoprolol, carvedilol, meto-prolol succinate, and nebivolol

sheet

cheat


Teaching yourpatient doesn’t

have to beexhausting.

Patient teaching for heart failureWhen teaching a patient with heart failure, be sure to cover:• the disorder, diagnosis, and treatment• signs and symptoms of worsening heart failure• when to notify the healthcare provider• the importance of follow-up care• the need to avoid high-sodium foods• the need to avoid fatigue• instructions about fluid restrictions• the need for the patient to weigh himself every morning at the same time, before eating and afterurinating, to keep a record of his weight, and to report a weight gain of 3 to 5 pounds (1.4 to 2.3kg) in 1 week• the importance of smoking cessation, if appropriate• medication dosage, administration, adverse reactions, and monitoring.

inhibitor or ARB, beta-blocker, and aldos-terone antagonist.

Devices and surgicalmanagementThere are several therapeutic options in ad-dition to pharmacologic management forthe treatment of heart failure, such as pac-ing; the use of an implantable cardioverterdefibrillator (ICD), ventricular assist device,or artificial heart; and heart transplantation.

If the underlying cause of the heart failureis treatable with surgery, then surgicaloptions should be the first explored. One ofthe most common surgical interventions isbiventricular pacing, also known as cardiacresynchronization therapy. This is recom-mended for patients who are NYHA ClassIII or Class IV with a QRS prolongation ofgreater than 120 ms who continue to experi-ence symptoms despite adequate pharmaco-logic therapy.

An ICD may be placed to prevent suddencardiac death caused by symptomatic andasymptomatic arrhythmias, which are seenfrequently in patients with heart failure. TheICD is a primary prevention to reduce mor-tality for patients with an EF of less than35%; it’s a secondary prevention for patientswho’ve survived a ventricular tachycardicevent.

Approved for both bridge-to-transplant

and destination therapy, left ventricularassist devices and artificial hearts are gainingmore popularity as technology advances.And new technologic developments in heartfailure devices continue to be made. Devicesthat are implanted under the skin have beendeveloped that help monitor the patient’sfluid status and then transmit the data backto the healthcare provider, which is helpfulin monitoring patients remotely. Thesedevices will hopefully prove to reduce hos-pitalizations for heart failure in the future.

Because the prognosis for patients withheart failure is so poor, the option of hearttransplantation continues to be a viablechoice. When a patient has reached the pointof end-stage heart failure, transplantation iscommonly addressed. There’s a verydetailed, complex process by which thepatient qualifies for transplantation; there-fore, it may not be an option for everypatient. You can be influential in educatingyour patient with heart failure about theoption of heart transplantation and the useof a ventricular assist device or artificialheart as a bridge to transplant, making surehe understands the magnitude of choosingone or both of these routes.

Lifestyle managementAs a nurse, the most important piece ofheart failure management is helping your

patients understand the lifestyle modifica-tions that are necessary when living withthis disease. Nurses must help patientslearn how to change their lives to benefittheir health. The first step is to stress theimportance of adherence to the treatmentregimen. In order to successfully treatheart failure, the patient must followthrough with taking medications and com-ing to follow-up appointments. Data haveshown that 20% to 60% of patients withheart failure don’t adhere to their pre-scribed treatment plan. You play an impor-tant role in educating your patients on thistopic.

You must also educate heart failurepatients about symptom recognition, weightmonitoring, diet and nutrition, and fluidintake. Intensive nursing-based educationprograms help patients understand theseconcepts and how they relate to treatingtheir disease. For example, if the patientunderstands which symptoms can alert him

to an oncoming exacerbation, he’ll know tocall the healthcare provider. Other topicsyou should address include alcohol cessa-tion, smoking cessation, weight loss, physi-cal activity, sexual activity, and pregnancy.By empowering the patient to embrace self-management, you can make the difference inyour patient’s prognosis (see Patient teachingfor heart failure).

Nursing interventions on paradeIn both inpatient and outpatient settings,nursing interventions for the patient withheart failure include the following:• administer medications and assess thepatient’s response to them• assess fluid balance, including intake andoutput, with a goal of optimizing fluid vol-ume• weigh the patient daily at the same timeon the same scale, usually in the morningafter the patient urinates (a 2- to 3-pound[0.9- to 1.4-kg] gain in a day or a 5-pound[2.3 kg] gain in a week indicates trouble)• auscultate lung sounds to detect an in-crease or decrease in pulmonary crackles• determine the degree of jugular vein dis-tension• identify and evaluate the severity ofedema (see Assessing for pitting edema)• monitor the patient’s pulse rate and BPand check for postural hypotension due todehydration• examine skin turgor and mucous mem-branes for signs of dehydration• assess for symptoms of fluid overload.

Evidence-based and on the ballHeart failure is a complex disease processthat affects millions of Americans. As anurse, you play an integral role in boththe management and treatment of thisdisease. Understanding the mechanismsof heart failure and the evidence-basedtherapies used to treat it continues to be apriority. n


Following the treatmentplan, a healthy diet,

and not smoking—nowthat’s a good start.

Assessing for pitting edema

(A) Apply finger pressure to an area near the ankle.

(B) When the pressure is released, an indentation remains in theedematous tissue.

A B

Learn more about itAmerican Association of Heart Failure Nurses. Compre-hensive Assessment and Symptoms of Heart Failure—CASH. http://aahfn.org/assets/Comprehensive_ Assessment_and_Symptoms_of_HF-CASH.pdf. Centers for Disease Control and Prevention. Heart failurefact sheet. http://www.cdc.gov/dhdsp/library/fs_heart_failure.htm.Gardetto NJ, Greaney K, Arai L, et al. Critical pathwayfor the management of acute heart failure at the VeteransAffairs San Diego Healthcare System: transforming per-formance measures into cardiac care. Crit Pathw Cardiol.2008;7(3):153-172.Heart Failure Society of America. The stages of heartfailure—NYHA classification. http://www.abouthf.org/questions_stages.htm.Hunt SA, American College of Cardiology, AmericanHeart Association Task Force on Practice Guidelines(Writing Committee to Update the 2001 Guidelines forthe Evaluation and Management of Heart Failure).ACC/AHA 2005 guideline update for the diagnosis andmanagement of chronic heart failure in the adult: a report

of the American College of Cardiology/American HeartAssociation Task Force on Practice Guidelines (WritingCommittee to Update the 2001 Guidelines for the Evalua-tion and Management of Heart Failure). J Am Coll Cardiol.2005;46(6):e1-e82.Institute for Healthcare Improvement. Deliver reliable,evidence-based care for congestive heart failure. http://www.ihi.org/IHI/Programs/Campaign/CHF.htm.Mayo Clinic. Heart failure. http://mayoclinic.com/print/heart-failure/DS00061/DSECTION=all&METHOD=print.Smeltzer SC, Bare BG, Hinkle JL. Brunner and Suddarth’sTextbook of Medical-Surgical Nursing. 11th ed. Philadelphia,PA: Lippincott Williams & Wilkins; 2007:946-957.Task Force for Diagnosis and Treatment of Acute andChronic Heart Failure 2008 of the European Society of Car-diology, Dickstein K, Cohen-Solal A, Filippatos G, et al.ESC guidelines for the diagnosis and treatment of acuteand chronic heart failure 2008: the Task Force for the Diag-nosis and Treatment of Acute and Chronic Heart Failure2008 of the European Society of Cardiology. Developed incollaboration with the Heart Failure Association of the ESC(HFA) and endorsed by the European Society of IntensiveCare Medicine (ESICM). Eur Heart J. 2008;29(19):2388-2442.


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