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Source: Rodgers JE, Lee CR. Acute Decompensated Heart Failure. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. Accessed June 29, 2012.

  • Exacerbation of heart failure (HF)

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

  • 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

  • Approximately 1 million Americans hospitalized annually for heart failure.

  • Prevention involves appropriate nonpharmacologic and pharmacologic treatment of HF.

  • Dietary indiscretions
  • Medication nonadherence
  • Use of medications that can exacerbate HF (e.g., nonsteroidal anti-inflammatory drugs)
  • New cardiac events (e.g., MI, atrial fibrillation)
  • Noncardiac illness (e.g., infection)

Signs and Symptoms

  • 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

Means of Confirmation and Diagnosis

  • See Heart Failure, Systolic.
  • Obtain medical history, focusing on precipitating factors; onset, duration, and severity of symptoms; and medication history.
  • On physical exam, assess vital signs, weight, and jugular venous pressure; identify presence of S3 gallop, crackles, and peripheral edema.

Laboratory Tests

  • B-type natriuretic peptide (BNP)
  • Serum electrolytes (including calcium and magnesium)
  • Renal function tests
  • Urinalysis

  • Relieve congestive symptoms.
  • Optimize volume status.
  • Treat symptoms of low cardiac output.
  • Minimize risks of drug therapy so patient can be discharged in compensated state on oral drug therapy.

  • Ensure optimal treatment with oral medications.
    • Provide aggressive diuresis (with IV diuretics if necessary) 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.
    • Consider digoxin at low dose to achieve trough serum concentration of 0.5–1 ng/mL.
  • Determine whether patient has fluid overload (“wet” HF) or low cardiac output (“dry” HF) (Figure 1).

Figure 1.

General treatment algorithm for acute decompensated heart failure (ADHF) based on clinical presentation. IV vasodilators that may be used include nitroglycerin, nesiritide, and nitroprusside. Metolazone or spironolactone may be added if patient fails to respond to loop diuretics and second diuretic required. IV inotropes that may be used include dobutamine and milrinone. (CI, cardiac index; CTZ, chlorothiazide; D/C, discontinue; HCTZ, hydrochlorothiazide; HF, heart failure; MAP, mean arterial pressure; PAC, pulmonary artery catheter; PAOP, pulmonary artery occlusion pressure; SBP, systolic blood pressure.) Reprinted with permission from Wells BG, DiPiro JT, Schwinghammer TL, et al. Pharmacotherapy Handbook. 8th ed. New York: McGraw-Hill, 2012.


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