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Acute heart failure: diagnosis and management (CG). © NICE .. decompensation of chronic heart failure. Acute heart .. this uncertainty and guide the management of a difficult clinical problem. Intra-aortic.
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Published online May Find articles by Tuija Javanainen. Find articles by Alexandre Mebazaa. Received Apr 11; Accepted May 2.

Decompensated heart failure

The Korean Society of Cardiology. Abstract Acute heart failure AHF is a life-threatening medical condition, where urgent diagnostic and treatment methods are of key importance. Heart failure, Cardiogenic shock, Management, Treatment.

Table 1 Precipitating factors of AHF 1 , 2. Open in a separate window.

Acute Heart Failure Management

Table 2 Clinical classification and appropriate treatment based on bedside clinical examination. Adjust oral therapy 1. Consider fluid challenge 1. Consider inotropic agent if hypoperfusion persists 2. Vasopressor in refractory cases 2. Diuretic when perfusion restored 3. Consider inotropic agent in refractory cases 4. Consider mechanical circulatory support if unresponsive to drugs. Time-based management in AHF. Initial clinical evaluation In the earliest stages of diagnostic workup, emphasis should be given to determination of cardiopulmonary stability based on dyspnea severity, hemodynamic status and heart rhythm.

Respiratory rate, orthopnea, accessory muscles use in respiration, visible cyanosis, pulse oximetry as objective measurements of respiratory distress. With expertise, thoracic ultrasound can be a useful diagnostic tool for visualizing directs signs of interstitial edema. It is one of the most used modalities in AHF settings.

Most specific signs of AHF are pulmonary venous congestion, pleural effusion, interstitial or alveolar edema and cardiomegaly. Immediate cardiac ultrasound is mandatory in all patients with CS and when acute life-threatening structural or functional cardiac abnormalities mechanical complications, aortic dissection, etc. Early echocardiography should be pursued in de novo AHF patients and those, whose cardiac function is unknown. Chest computed tomography CT: Due to their high sensitivity, NPs are very important in ruling out AHF as an etiology of acute dyspnea, since detecting normal levels makes AHF diagnosis improbable.

Therefore, a higher value of NP does not automatically confirm the diagnosis of AHF and interpretation of their levels must be combined with clinical assessment and cardiac imaging. The following laboratory assessments should be performed at admission in all patients with AHF: Elevated cholestasis markers are associated with signs of systemic congestion, right HF and higher concentration of creatinine and NPs, whereas increased levels of alanine aminotransferase, aspartate aminotransferase — with signs of hypoperfusion and consequent liver cell damage.

Although not needed in most cases, arterial blood gas may be useful in severe cases of hemodynamic instability and respiratory distress. Acid-base balance should be obtained on admission, especially in patients with APE or previous history of chronic obstructive pulmonary disease COPD. First day management After initial diagnostic tests and symptomatic treatment of the urgent symptoms, clinicians should seek to rapidly identify the etiology or precipitating factor for AHF and initiate the specific treatment Figure 1.

Tachyarrhythmia, bradyarrythmia or conduction disturbances may precipitate AHF. Several ESC guidelines address the management of severe rhythm disturbances. They include complications of ACS e. Immediate echocardiography is crucial to confirm the diagnosis when acute mechanical cause is suspected and treatment comprises of urgent surgical or percutaneous repair. Pulmonary embolus should be considered as a precipitant of AHF since patients with HF are more likely to be in a hypercoagulable state.

This may be achieved by thrombolysis, catheter-based approach or surgical embolectomy. Respiratory infections are frequent precipitants for HF.

Acute Heart Failure Management

Determining necessary level of care for acute heart failure patient AHF patients need different levels of care discharge, observation, ward, ICU, etc. Subjective improvement noted by patient. No or moderate worsening of renal function chronic renal disease might be present 3. First week management Monitoring in the hospital AHF patients should be carefully monitored in the hospital. Evidence based oral heart failure therapies The patient's compliance with HF medications should be reviewed at admission and adjustments should be made, if needed.

Discharge phase and early follow-up In the discharge phase, clinicians should assess functional capacity of patient and potential exacerbating factors, optimize pharmacologic therapy and establish post-discharge plans together with the patient. Provided with self-care education. Seen by their general practitioners within 1 week of discharge and by the hospital based cardiologist within 2 weeks.

Followed-up within a multidisciplinary HF service 1 , 3. Contributed by Author Contributions: Eur J Heart Fail. Acute heart failure and cardiogenic shock: Contemporary management of acute right ventricular failure: East Asia may have a better 1-year survival following an acute heart failure episode compared with Europe: Medical management of advanced heart failure. Design of therapy for advanced heart failure.

Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. J Am Coll Cardiol. Clinical profile, contemporary management and one-year mortality in patients with severe acute heart failure syndromes: Timing of immunoreactive B-type natriuretic peptide levels and treatment delay in acute decompensated heart failure: Early vasoactive drugs improve heart failure outcomes.

Effects of prehospital medications on mortality and length of stay in congestive heart failure.


Effect of cardiogenic shock hospital volume on mortality in patients with cardiogenic shock. J Am Heart Assoc. Picano E, Pellikka PA. Ultrasound of extravascular lung water: Point-of-care ultrasonography for the diagnosis of acute cardiogenic pulmonary edema in patients presenting with acute dyspnea: Prevalence of negative chest radiography results in the emergency department patient with decompensated heart failure. Clinical, radiographic, and hemodynamic correlations in chronic congestive heart failure: Value of natriuretic peptides in assessment of patients with possible new heart failure in primary care.

Incremental value of biomarkers to clinical variables for mortality prediction in acutely decompensated heart failure: Serial high sensitivity cardiac troponin T measurement in acute heart failure: Cardiac troponin and outcome in acute heart failure. N Engl J Med. Liver function abnormalities, clinical profile, and outcome in acute decompensated heart failure. The prognostic implications of renal insufficiency in asymptomatic and symptomatic patients with left ventricular systolic dysfunction.

Peripheral venous blood gases and pulse-oximetry in acute cardiogenic pulmonary oedema. Noninvasive ventilation in acute cardiogenic pulmonary edema: A randomized study of out-of-hospital continuous positive airway pressure for acute cardiogenic pulmonary oedema: Diuretics for heart failure.


Cochrane Database Syst Rev. CD [ PubMed ]. Acute applications of noninvasive positive pressure ventilation. Diuretic strategies in patients with acute decompensated heart failure. Decongestion in acute heart failure. Loop diuretic resistance in heart failure: Cardiorenal outcomes after slow continuous ultrafiltration therapy in refractory patients with advanced decompensated heart failure. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema.

Effect of ularitide on cardiovascular mortality in acute heart failure. Serelaxin in addition to standard therapy in acute heart failure: Teerlink JR, Marco M.

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European Society of Cardiology; Clevidipine in acute heart failure: Agents with vasodilator properties in acute heart failure: Morphine and outcomes in acute decompensated heart failure: Long-term safety of intravenous cardiovascular agents in acute heart failure: Treatment with inotropes and related prognosis in acute heart failure: J Heart Lung Transplant. Short-term survival by treatment among patients hospitalized with acute heart failure: Acute heart failure syndromes in patients with coronary artery disease early assessment and treatment.

Troponin elevation in heart failure prevalence, mechanisms, and clinical implications. Factors identified as precipitating hospital admissions for heart failure and clinical outcomes: Effect of precipitating factors of acute heart failure on readmission and long-term mortality. Actual incidence of global left ventricular hypokinesia in adult septic shock. Use of procalcitonin for the diagnosis of pneumonia in patients presenting with a chief complaint of dyspnoea: The role of procalcitonin in acute heart failure patients. Procalcitonin-based indication of bacterial infection identifies high risk acute heart failure patients.

Risk stratification for in-hospital mortality in acutely decompensated heart failure: Worsening renal function and prognosis in heart failure: Diagnoses and timing of day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. The authors designed, jointly reviewed and revised the initial draft and subsequent versions of the manuscript, and both agreed on the final version submitted for publication. The sponsor reviewed the drafts of the manuscript for proprietary evaluation and own study data accuracy. Oxford University Press is a department of the University of Oxford.

It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Close mobile search navigation Article navigation. Treatment options for acute heart failure in advanced development stage. Other emerging therapeutic approaches for acute heart failure. Central role of biomarkers in acute heart failure management.

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Overall conclusions and summary. What is on the horizon for improved treatments for acutely decompensated heart failure? Acute heart failure , Unmet need , Novel therapies , Biomarkers , Organ damage , Clinical management. No significant effect was observed on the other primary endpoint, relief from dyspnoea as assessed with the Likert scale during the first 24 h Figure 1. View large Download slide. At 24 h, plasma NT-proBNP levels were reduced in patients receiving ularitide, compared with placebo. Improving care for patients with acute heart failure: Serelaxin for the treatment of acute heart failure: Clinical trials in acute heart failure: Consensus document arising from a European Society of Cardiology cardiovascular round-table think tank on acute heart failure, 12 May A novel therapy for acute heart failure with a range of hemodynamic and non-hemodynamic actions.

Effects of serelaxin in acute heart failure patients with renal impairment: Serelaxin in acute heart failure patients with preserved left ventricular ejection fraction: Effects of serelaxin in subgroups of patients with acute heart failure: The natriuretic peptides system in the pathophysiology of heart failure: Ularitide for the treatment of acute decompensated heart failure: Effects of the renal natriuretic peptide urodilatin ularitide in patients with decompensated chronic heart failure: Dendroaspis natriuretic peptide and the designer natriuretic peptide, CD-NP, are resistant to proteolytic inactivation.

Design, synthesis, and actions of a novel chimeric natriuretic peptide: Pharmacodynamics of a novel designer natriuretic peptide, CD-NP, in a first-in-human clinical trial in healthy subjects. A Phase II, dose-ranging study with CD-NP, a chimeric natriuretic peptide, in acute decompensated heart failure patients with renal compromise. A new approach to inotropic therapy in the treatment of heart failure: Cardiac myosin activators for the treatment of heart failure: Cinaciguat, a soluble guanylate cyclase activator, unloads the heart but also causes hypotension in acute decompensated heart failure.

Cinaciguat, a soluble guanylate cyclase activator: Istaroxime stimulates SERCA2a and accelerates calcium cycling in heart failure by relieving phospholamban inhibition. Effects of istaroxime on diastolic stiffness in acute heart failure syndromes: Calcium upregulation by percutaneous administration of gene therapy in patients with cardiac disease CUPID 2: Molecular mechanism of beta-arrestin-biased agonism at seven-transmembrane receptors.

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Cardiorenal actions of TRV, a novel ss-arrestin-biased ligand at the angiotensin II type I receptor, in healthy and heart failure canines: TRV, a novel beta-arrestin biased ligand at the angiotensin II type I receptor, unloads the heart and maintains renal function when added to furosemide in experimental heart failure. Selectively engaging beta-arrestins at the angiotensin II type 1 receptor reduces blood pressure and increases cardiac performance.

Heart failure therapeutics on the basis of a biased ligand of the angiotensin-2 type 1 receptor. Phase 2b proof of concept study in AHF. A novel approach for the acute treatment of heart failure. New therapeutic perspectives with clevidipine: Clevidipine for severe hypertension in acute heart failure: Clevidipine in acute heart failure: Acute effects of intravenous nicorandil on hemodynamics in patients hospitalized with acute decompensated heart failure. Effects of intravenous nicorandil on the mid-term prognosis of patients with acute heart failure syndrome.

Effect of nicorandil in patients with heart failure: FDA approves Corlanor to treat heart failure.

USMLE Step 1: Acute Heart Failure

Prognostic markers of acute decompensated heart failure: Biomonitoring and biomarker-guided therapy: Biomarker-guided therapy in chronic heart failure: NT-proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: The diagnostic accuracy of the natriuretic peptides in heart failure: Prognostic value and kinetics of soluble Neprilysin in acute heart failure: The real-life value of ST2 monitoring during heart failure decompensation: Use of high-sensitivity Troponin T to identify patients with acute heart failure at lower risk for adverse outcomes: Elevated D-dimer levels predict an adverse outcome in hospitalized patients with acute decompensated heart failure.

Mid-region pro-hormone markers for diagnosis and prognosis in acute dyspnea: Published on behalf of the European Society of Cardiology. For permissions please email: Email alerts New issue alert. Receive exclusive offers and updates from Oxford Academic.