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  • Image not available. Unlike chronic heart failure therapies whose primary benefit is an improvement in survival, treatment goals of acute decompensated heart failure (ADHF) are directed toward relief of symptoms of pulmonary edema, restoration of systemic oxygen transport and tissue perfusion, and limitation of further cardiac damage and other adverse effects.
  • Image not available. Maximizing oral chronic heart failure therapy and using combinations of short-acting intravenous medications with different cardiovascular actions are often needed to optimize cardiac output, relieve pulmonary edema, and limit myocardial ischemia.
  • Image not available. Patients presenting to the hospital with ADHF can be categorized into four subsets based upon fluid status (euvolemic or “dry” vs fluid overload or “wet”) and cardiac output (adequate cardiac output or “warm” vs hypoperfusion or “cold”). Thus, patients are warm and dry, warm and wet, cold and dry, or cold and wet.
  • Image not available. While invasive hemodynamic monitoring using a pulmonary artery or Swan Ganz catheter has been shown to not alter outcomes in a broad population of ADHF patients not requiring such monitoring, it is indicated for patients who are refractory to initial therapy, whose volume status is unclear, or who have clinically significant hypotension such as a systolic blood pressure less than 80 mm Hg or worsening renal function despite therapy. In addition, pulmonary artery catheter monitoring may also be necessary to provide immediate feedback on treatment efficacy and adverse effects.
  • Image not available. Key hemodynamic parameters to assess with pulmonary artery catheter monitoring include pulmonary capillary wedge pressure, which reflects fluid status or preload; cardiac output, which reflects the innate contractility of the heart; and systemic vascular resistance, which reflects vascular tone or afterload. While a normal pulmonary capillary wedge pressure (6 to 12 mm Hg) is desirable in most healthy patients, higher filling pressures (15 to 18 mm Hg) are necessary in patients with heart failure.
  • Image not available. Three major therapeutic categories exist for managing ADHF: diuretics, inotropes, and vasodilators. No therapy for ADHF studied to date has been shown conclusively to decrease mortality. Inotropic therapy consistently has been associated with increased mortality and adverse effects in multiple studies.
  • Image not available. Intravenous loop diuretics are considered first-line therapy for management of ADHF associated with fluid overload. A variety of therapeutic options are recommended for managing refractory fluid overload, including increasing loop diuretic intravenous bolus dose, adding a diuretic with a different mechanism of action, and transitioning to a continuous infusion of loop diuretic. Ultrafiltration is also an option for patients refractory to diuretics. If patients continue to be refractory to and experience worsening renal function with diuretic therapy, vasodilator and inotropic therapy may be indicated. Placement of a pulmonary artery catheter may be helpful in guiding therapy in such patients.
  • Image not available. Intravenous inotropes are recommended for symptom relief or end-organ dysfunction for patients with left ventricular dysfunction and low cardiac output syndrome. Such therapy may be especially useful for patients with low systolic blood pressure (less than 90 mm Hg) or symptomatic hypotension in the setting of adequate filling pressures. Inotropic therapy may also be considered for patients who do not tolerate or ...

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