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Diagnostic and Therapeutic Approach to Acute Decompensated Heart Failure

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Abstract

Heart failure afflicts large numbers of patients and is the leading cause for hospitalizations in the United States. Diagnosis and management of decompensated heart failure present a clinical challenge, requiring complex decision-making. History and physical examination findings are important in the diagnosis of heart failure. Diagnostically, B-type natriuretic peptide levels appear very useful to separate cardiac from noncardiac causes of dyspnea and provide information about heart failure severity and prognosis. Immediate management goals include improvement of symptoms and hemodynamic parameters. Diuretics, vasodilators, and inotropic agents are useful in the acute setting. This article provides a systematic approach to the diagnosis and management of acute decompensated heart failure.

Section snippets

Diagnosis

Assuring the correct diagnosis of acute decompensated heart failure is a clinical challenge. Surveyed physicians were uncertain about the diagnosis in approximately 60% of cases; the misdiagnosis rate is as high as 10%-20%.5, 6 A carefully completed history and physical examination is the cornerstone of diagnosis. Symptoms of worsening fluid retention or decreasing exercise tolerance related to increasing left or right ventricular filling pressures are often present. They are usually

Therapeutic approaches

Attention should first be directed to the ABCs of airway, breathing, and circulation in patients with acute pulmonary edema. Supplemental oxygen, noninvasive positive pressure ventilation, and mechanical ventilation are considered for hypoxemic and hypercarbic patients. Positive pressure ventilation decreases pulmonary edema, because increases in intrathoracic pressure decrease venous return. Symptomatic treatment strategies, namely relief of dyspnea and exercise intolerance, are mainstays of

Diuretics

Because patients with acute decompensated heart failure present with signs of circulatory congestion, intravenous diuretic therapy is first-line therapy. Loop diuretics relieve volume overload by promoting a net diuresis by inhibiting sodium reabsorption in the loop of Henle. Greater diuresis is achieved with loop diuretics when compared with distal-acting diuretics because of their proximal site of action in the kidney. Diuretics should be administered as an intravenous bolus to ensure maximal

Vasodilators

Patients demonstrating an inadequate response to diuretic therapy as evidenced by continued symptomatic deterioration (increased oxygen requirements, fatigue), congestion (orthopnea, jugular venous distension, rales, S3 gallop, edema) and preserved perfusion (warm extremities) are classified as “warm and wet” (Figure 2).33 Such patients are moderately to severely volume-overloaded with elevated left ventricular filling pressures and require more aggressive treatment with vasodilators provided

Inotropic agents

Patients with decreased urine output, cool extremities, narrow pulse pressure, prerenal physiology, and altered mental status are likely suffering from low cardiac output. This represents <1% of all presentations.49 Inotropic therapy should be considered in patients with this “cool and dry” type of heart failure. Dobutamine and milrinone usually produce short-term symptomatic and hemodynamic improvement.50 Dobutamine increases cardiac output by stimulating cardiac beta-receptors. This increases

Conclusions

Acute decompensated heart failure presents a challenge to the clinician that usually requires complex decision-making. The diagnosis requires a thorough history and physical examination, often with adjunctive tests. Immediate management goals include improvement of symptoms and hemodynamic parameters (Table 2). Current treatment standards demonstrate beneficial effects on both parameters, although effects on long-term mortality are lacking. Future studies need to better address how to reduce

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