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SOURCE

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Source: Rodgers JE, Reed BN. Acute decompensated heart failure. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146056502. Accessed May 11, 2017.

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CONDITION/DISORDER SYNONYM

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  • Exacerbation of heart failure (HF)

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DEFINITION

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  • New or worsening signs or symptoms of HF usually caused by volume overload and/or hypoperfusion that necessitates emergency department visits or hospitalizations.

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ETIOLOGY

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  • Factors that may precipitate decompensation.

    • Myocardial ischemia and myocardial infarction (MI)

    • Atrial fibrillation.

    • Pulmonary infection.

    • Nonadherence with diet or drug therapy.

    • Use of medications with negative inotropic, cardiotoxic, or sodium- and water-retaining properties.

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PATHOPHYSIOLOGY

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EPIDEMIOLOGY

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  • Approximately 1 million Americans are hospitalized annually for heart failure.

  • Hospitalization for HF has been independently associated with increases in subsequent hospitalization as well as decreased survival.

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PREVENTION AND SCREENING

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  • Prevention involves appropriate nonpharmacologic and pharmacologic treatment of HF.

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RISK FACTORS

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  • Dietary indiscretions.

  • Medication nonadherence.

  • Use of medications that can exacerbate HF (eg, nonsteroidal anti-inflammatory drugs)

  • New cardiac events (eg, MI, atrial fibrillation)

  • Noncardiac illness (eg, infection)

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CLINICAL PRESENTATION

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SIGNS AND SYMPTOMS
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  • Symptoms:

    • Dyspnea on exertion.

    • Fatigue.

    • Exercise intolerance.

    • Orthopnea.

    • Paroxysmal nocturnal dyspnea.

    • Tachypnea.

    • Cough.

  • Signs:

    • Crackles.

    • S3 gallop.

    • Cool extremities.

    • Cheyne–Stokes respiration.

    • Tachycardia.

    • Narrow pulse pressure.

    • Cardiomegaly.

    • Peripheral edema.

    • Jugular venous distention.

    • Hepatojugular reflux.

    • Hepatomegaly.

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DIAGNOSIS

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MEANS OF CONFIRMATION AND DIAGNOSIS
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  • See Heart Failure, Systolic.

  • Obtain medical history, focusing on precipitating factors; onset, duration, and severity of symptoms; and medication history.

  • On physical examination, assess vital signs, weight, and jugular venous pressure; identify presence of S3 gallop, crackles, and peripheral edema.

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LABORATORY TESTS
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  • B-type natriuretic peptide (BNP)

  • Serum electrolytes (including calcium and magnesium)

  • Renal function tests.

  • Urinalysis.

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DESIRED OUTCOMES

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  • Relieve congestive symptoms.

  • Optimize volume status.

  • Treat symptoms of low cardiac output.

  • Minimize risks of drug therapy.

  • Discharge patient in compensated state on oral drug therapy.

  • Optimize chronic oral therapy and patient education to prevent rehospitalization.

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TREATMENT: GENERAL APPROACH

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  • Assess medications being taken prior to admission and determine whether adjustment or discontinuation is required.

  • Acute management of ADHF is based primarily on hemodynamic status.

  • Ensure optimal treatment with oral medications.

    • Provide aggressive diuresis (with intravenous [IV] diuretics) if evidence of fluid retention.

    • Ensure optimal ACE (angiotensin-converting-enzyme) inhibitor treatment.

    • Do not start β-blockers during instability but continue if possible in patients already receiving them chronically.

  • Determine whether patient has fluid overload (“wet” HF) or low cardiac output (“dry” ...

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