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  • image Unlike chronic heart failure therapies whose primary role is to improve survival, treatment goals for acute decompensated heart failure (ADHF) are directed toward relief of congestive symptoms, restoration of systemic oxygen transport and tissue perfusion through improved myocardial contractility, and minimization of further cardiac damage and other adverse effects.
  • image Maximizing oral chronic heart failure therapy may assist with optimizing cardiac output and relieving congestion.
  • image Patients presenting to the hospital with ADHF can be categorized into four subsets based upon fluid status (euvolemic or “dry” vs. fluid overloaded or “wet”) and cardiac function (adequate cardiac output or “warm” vs. hypoperfusion or “cold”). Therefore, patients are either warm and dry, warm and wet, cold and dry, or cold and wet.
  • image While invasive hemodynamic monitoring using a PA catheter does not alter outcomes in a broad population of ADHF patients, it is indicated in those who are refractory to initial therapy, whose volume status is unclear, or who have clinically significant hypotension (i.e., systolic blood pressure less than 80 mm Hg) or worsening renal function despite therapy.
  • image Key hemodynamic parameters to monitor with a PA catheter include pulmonary capillary wedge pressure (PCWP; reflecting fluid status or “preload”), cardiac output or cardiac index (CI; reflecting the innate contractility of the heart), and systemic vascular resistance (reflecting vascular tone or “afterload”). While a normal PCWP (6 to 12 mm Hg) is desirable in healthy patients, higher filling pressures (15 to 18 mm Hg) are often necessary in patients with heart failure.
  • image Three major therapeutic categories exist for the management of ADHF including diuretics, inotropes, and vasodilators. No therapy studied to date has conclusively been shown to decrease mortality and several may potentially worsen outcomes.
  • image IV loop diuretics are considered first-line therapy for the management of ADHF associated with fluid overload nonresponsive to orally administered diuretics. While a variety of therapeutic options may be considered for refractory fluid overload, a recent clinical trial demonstrated no difference in outcomes between bolus and continuous administration of IV diuretics; however, administering high-dose IV diuretic (2.5-times the previous oral regimen) is associated with greater fluid removal rate. If patients continue to be refractory to, or experience worsening renal function with diuretic therapy, vasodilatory and inotropic therapy may be indicated. Placement of a pulmonary artery (PA) catheter may be helpful in guiding therapy in such patients.
  • image IV inotropes are recommended for symptom relief or end-organ dysfunction in patients with left ventricular dysfunction and low cardiac output. Such therapy may be especially useful in 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 in patients who do not tolerate or respond to IV vasodilators or in patients with worsening renal function, but should be avoided in patients with reduced left heart filling pressures. Patients receiving these agents should be monitored continuously for arrhythmias.
  • image Given the potential risks associated with inotropic therapy, vasodilators should be considered prior to their use.
  • image IV vasodilators ...

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