Acute decompensated heart failure Acute decompensated heart failure (ADHF) is a clinical syndrome of worsening signs or symptoms of heart failure requiring hospitalization or other unscheduled medical care. For many years, ADHF was viewed as simply an exacerbation of chronic heart failure as a result of volume overload, with little implications beyond a short-term need to intensify diuretic therapy. Multiple lines of evidence now support the concept that ADHF is a unique clinical syndrome with its own epidemiology and underlying mechanisms and a need for specific therapies. ADHF is not just a worsening of chronic heart failure (HF) any more than an acute myocardial infarction (MI) is just a worsening of chronic angina. Outcomes data from a variety of studies now support the concept that hospitalization for ADHF can often signal a dramatic change in the natural history of the heart failure syndrome. Rates of rehospitalization or death are as high as 50% within 6 months of the initial ADHF event, which is a much higher event rate than is seen with acute MI. Clinically important subcategories of ADHF: There is great interest in developing a framework for understanding ADHF that would assist in stratifying patients, guiding therapy, and developing new treatments, similar to the basic framework developed for acute coronary syndromes (i.e., ST-segment-elevation myocardial infarction [STEMI], non–ST-segment-elevation myocardial infarction [NSTEMI], and unstable angina). Although this area is rapidly evolving, a few general clinical phenotypes of ADHF have emerged. 1. Hypertensive acute heart failure: Data from large registries such as ADHERE and OPTIMIZE have shown that a substantial portion of ADHF patients are hypertensive on initial presentation to the emergency department. Such patients often have relatively little volume overload and preserved or only mildly reduced ventricular function and are more likely to be older and female. Symptoms often develop quickly (minutes to hours), and many such patients have little or no history of chronic heart failure. Hypertensive urgency with acute pulmonary edema represents an extreme form of this phenotype. 2. Decompensated heart failure: This describes patients with a background of significant chronic heart failure, who develops symptoms of volume overload and congestion over a period of days to weeks. These patients typically have significant left ventricular dysfunction and chronic heart failure at baseline. Although specific triggers are poorly understood, episodes are often triggered by noncompliance with diet or medical therapy. 3. Cardiogenic shock/advanced heart failure: Although patients with advanced forms of heart failure are often seen in tertiary care centers, they are relatively uncommon in the broader population (probably fewer than 10% of ADHF hospitalizations). These patients often present with so called low-output symptoms that may make diagnosis challenging, including confusion, fatigue, abdominal pain, or anorexia. Hypotension (systolic blood pressure [SBP] less than 90 mm Hg) and significant end-organ dysfunction (especially renal dysfunction) are common features. Many of these patients have concomitant evidence of significant right ventricular dysfunction, with ascites or generalized anasarca. Treatment goals of ADHF • Improve symptoms of congestion • Optimize volume status • Identify and address triggers for decompensation • Optimize chronic oral therapy • Minimize side effects • Identify patients who might benefit from revascularization • Educate patients concerning medications and disease management Criteria for hospital discharge for ADHF • Exacerbating factors addressed • Near optimal volume status achieved • Transitioned from IV to oral therapy (consider 24 hours of stability on oral therapy for high-risk patients) • Education of patient and family • Near optimal chronic heart failure therapy achieved • Follow-up appointment scheduled in 7 to 10 days (earlier if high risk)
Posted on: Mon, 10 Mar 2014 17:13:13 +0000
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