TREATMENT OF ACUTE DECOMPENSATED HEART FAILURE
GENERAL APPROACH
• Acute decompensated heart failure (ADHF) involves patients with new or worsen-
ing signs or symptoms (often resulting from volume overload and/or hypoperfu-
sion) requiring additional medical care, such as emergency department visits and
hospitalizations.
• Goals of Treatment: Relieve congestive symptoms, optimize volume status, treat
symptoms of low cardiac output, and minimize risks of drug therapy so the patient
can be discharged in a compensated state on oral drug therapy.
• Hospitalization is recommended or should be considered depending on patient pre-
sentation. Admission to an intensive care unit (ICU) may be required if the patient
experiences hemodynamic instability requiring frequent monitoring, invasive hemo-
dynamic monitoring, or rapid titration of IV medications with close monitoring.
• Address and correct reversible or treatable causes of decompensation. Medications
that may aggravate HF should be evaluated carefully and discontinued when possible.
• The first step in managing ADHF is to ascertain that optimal treatment with oral
medications has been achieved. If fluid retention is evident, aggressive diuresis, often
with IV diuretics, should be accomplished. Standard treatment should be optimized
with an ACE inhibitor and β-blocker. β-blockers should generally be continued dur-
ing hospitalization unless recent dose initiation or up-titration was responsible for
, decompensation. In such cases, β-blocker therapy may be temporarily withheld or
dose-reduced. Most patients may continue to receive digoxin at a low dose targeting
a trough serum concentration of 0.5–1 ng/mL (0.6–1.3 nmol/L).
• Appropriate management of ADHF is aided by determination of whether the patient
has signs and symptoms of fluid overload (“wet” HF) or low cardiac output (“dry” HF)
(Fig. 9–2).
• Invasive hemodynamic monitoring in select patients may help guide treatment and
classify patients into four specific hemodynamic subsets based on cardiac index and
pulmonary artery occlusion pressure (PAOP).
PHARMACOTHERAPY OF ACUTE DECOMPENSATED HEART FAILURE
Diuretics
• IV loop diuretics, including furosemide, bumetanide, and torsemide, are used for
ADHF, with furosemide being the most widely studied and used agent.
82
SECTION 2 | Cardiovascular Disorders
MAP >50 mm Hg
Yes No
SBP <90 mm Hg
Symptomatic hypotension
Worsening renal function
Dopamine
No
IV Diuretics
± IV Vasodilators
GENERAL APPROACH
• Acute decompensated heart failure (ADHF) involves patients with new or worsen-
ing signs or symptoms (often resulting from volume overload and/or hypoperfu-
sion) requiring additional medical care, such as emergency department visits and
hospitalizations.
• Goals of Treatment: Relieve congestive symptoms, optimize volume status, treat
symptoms of low cardiac output, and minimize risks of drug therapy so the patient
can be discharged in a compensated state on oral drug therapy.
• Hospitalization is recommended or should be considered depending on patient pre-
sentation. Admission to an intensive care unit (ICU) may be required if the patient
experiences hemodynamic instability requiring frequent monitoring, invasive hemo-
dynamic monitoring, or rapid titration of IV medications with close monitoring.
• Address and correct reversible or treatable causes of decompensation. Medications
that may aggravate HF should be evaluated carefully and discontinued when possible.
• The first step in managing ADHF is to ascertain that optimal treatment with oral
medications has been achieved. If fluid retention is evident, aggressive diuresis, often
with IV diuretics, should be accomplished. Standard treatment should be optimized
with an ACE inhibitor and β-blocker. β-blockers should generally be continued dur-
ing hospitalization unless recent dose initiation or up-titration was responsible for
, decompensation. In such cases, β-blocker therapy may be temporarily withheld or
dose-reduced. Most patients may continue to receive digoxin at a low dose targeting
a trough serum concentration of 0.5–1 ng/mL (0.6–1.3 nmol/L).
• Appropriate management of ADHF is aided by determination of whether the patient
has signs and symptoms of fluid overload (“wet” HF) or low cardiac output (“dry” HF)
(Fig. 9–2).
• Invasive hemodynamic monitoring in select patients may help guide treatment and
classify patients into four specific hemodynamic subsets based on cardiac index and
pulmonary artery occlusion pressure (PAOP).
PHARMACOTHERAPY OF ACUTE DECOMPENSATED HEART FAILURE
Diuretics
• IV loop diuretics, including furosemide, bumetanide, and torsemide, are used for
ADHF, with furosemide being the most widely studied and used agent.
82
SECTION 2 | Cardiovascular Disorders
MAP >50 mm Hg
Yes No
SBP <90 mm Hg
Symptomatic hypotension
Worsening renal function
Dopamine
No
IV Diuretics
± IV Vasodilators
