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BASICS

Description

  • ADHF: new onset or worsening heart failure with impaired ventricular filling or ejection
  • Manifestations: pulmonary/systemic congestion, tissue hypoperfusion, cardiogenic shock in severe cases
  • May represent acute HF or decompensation of chronic HF
  • Clinical profiles: volume overload, depressed cardiac output, or mixed

Epidemiology

  • HF common cause of hospitalization in >65 years
  • ~1 million hospitalizations/year in the US
  • Poor long-term prognosis: ~50% mortality at 5 years, 90% at 10 years

Etiology & Pathophysiology

  • Systolic dysfunction (inotropic impairment) and/or diastolic dysfunction (compliance abnormality)
  • HF types: HFrEF, HFmrEF, HFpEF, HFimpEF
  • Common triggers: medication noncompliance, CAD, MI, hypertension, arrhythmias, valvular disease, pericardial/endocardial disease, toxins, metabolic derangements

Risk Factors & Associated Conditions

  • See Heart Failure, Chronic topic
  • Common comorbidities: CAD, CKD, diabetes, dysrhythmias

DIAGNOSIS

History & Physical Exam

  • Typical history: prior HF, MI, uncontrolled hypertension
  • Symptoms: dyspnea on exertion, orthopnea (high sensitivity, low specificity)
  • PE: S3 gallop (highest positive LR), lung rales, wheezing, Cheyne-Stokes respiration

Differential Diagnosis

  • Exclude PE, MI, tamponade, pneumothorax, ARDS, sepsis, COPD, pneumonia, constrictive pericarditis, high-output states

Diagnostic Tests

  • Labs: BUN, creatinine, electrolytes, LFTs, TSH, UA, glucose, CBC, troponins, BNP/NT-proBNP
  • ECG: assess for ischemia, arrhythmia
  • Chest X-ray: assess pulmonary congestion, alternate diagnoses
  • Echocardiogram: immediate if unstable or unknown cardiac status
  • Lung ultrasound: presence of B lines suggests pulmonary edema (high specificity)
  • Cardiac catheterization if ischemic cause suspected
  • Pulmonary artery catheterization rare, reserved for cardiogenic shock

TREATMENT

Goals

  • Improve hemodynamics and organ perfusion
  • Relieve symptoms
  • Prevent cardiac and renal injury
  • Optimize long-term management and education

Initial Management

  • Assess hemodynamics; treat accordingly
  • Hypertensive ADHF: IV vasodilators (nitroglycerin, nitroprusside) to reduce preload/afterload
  • Hypotensive/shock: vasopressors/inotropes as needed
  • Respiratory support: early noninvasive positive pressure ventilation (NIPPV) with CPAP/BiPAP improves outcomes

Medications

First Line

  • IV loop diuretics (furosemide, torsemide preferred for pharmacokinetics) for fluid overload; dose adjusted based on prior outpatient dose and urine output
  • Add thiazides (metolazone) or mineralocorticoid receptor antagonists (spironolactone) if diuresis inadequate
  • Vasodilators: IV nitroglycerin (10-20 mcg/min up to 200 mcg/min), nitroprusside (start 0.3 mcg/kg/min)
  • IV ACE inhibitors: uncertain evidence, may reduce preload/afterload

Second Line

  • Tolvaptan: under study for severe hypervolemic hyponatremia refractory to other therapies
  • Inotropes: milrinone, dobutamine (monitor closely; avoid in cardiogenic shock or tachyarrhythmias)
  • Vasopressors: if shock persists despite inotropes

Avoid

  • Nesiritide, ultrafiltration, levosimendan not routinely recommended

Additional Therapies

  • Oxygen therapy to maintain saturation >92% (88-92% in COPD)
  • Transfusion for anemia if Hgb <8 g/dL (target ~10 g/dL)
  • Address underlying cause: revascularization, valve surgery, pericardiectomy as needed

Surgical/Procedural

  • Valve surgery for significant valvular disease
  • PCI or CABG for CAD/MI
  • Pericardiectomy for constrictive pericarditis

ADMISSION & NURSING

Admission Criteria

  • Severe decompensation: hypotension, altered mental status, dyspnea at rest, arrhythmia, ACS, worsening renal function
  • Observation unit for stable patients with controlled vitals, no ischemia, and low BNP

Discharge Criteria

  • Improved symptoms
  • SBP 100-120 mm Hg
  • Good urine output
  • Serum sodium >135 mEq/L
  • Completion of HF education

ONGOING CARE

Follow-Up

  • Early post-discharge multidisciplinary care to reduce rehospitalization and mortality

Diet & Lifestyle

  • Fluid restriction (1.5-2.0 L/day) may reduce congestion symptoms
  • See Heart Failure, Chronic for diet and risk factor modifications

Patient Education

  • Medication adherence, activity guidance, daily weight monitoring, symptom recognition

PROGNOSIS & COMPLICATIONS

Prognosis

  • Refer to chronic HF topic; high morbidity and mortality persist

Complications

  • Arrhythmias
  • Pulmonary edema
  • Hyponatremia
  • Death

Clinical Pearls

  • Identify and treat underlying cause of each ADHF episode
  • Early use of NIPPV improves respiratory outcomes and mortality
  • IV diuretics should be initiated promptly in fluid overloaded patients
  • Vasodilators useful in hypertensive patients; use with caution in hypotension
  • Inotropes and vasopressors reserved for cardiogenic shock

References

  1. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. Circulation. 2022;145(18):e895-e1032. Full Text