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. http://accesspharmacy.com/content.aspx?aid=7971596.
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
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
- New cardiac events (e.g., MI, atrial fibrillation)
- Noncardiac illness (e.g., infection)
- Dyspnea on exertion
- Exercise intolerance
- Paroxysmal nocturnal dyspnea
- S3 gallop
- Cool extremities
- Cheyne–Stokes respiration
- Narrow pulse pressure
- Peripheral edema
- Jugular venous distention
- Hepatojugular reflux
Means of Confirmation
- 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
- B-type natriuretic peptide (BNP)
- Serum electrolytes (including calcium and magnesium)
- Renal function tests
- 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
- 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).
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.