Acute Decompensated Heart Failure (ADHF)

1️⃣ What is ADHF?

Acute Decompensated Heart Failure (ADHF) is the rapid onset or worsening of signs and symptoms of heart failure requiring urgent therapy and often hospitalization.

It may occur as:

• De novo HF (newly diagnosed)
• Acute decompensation of chronic HF
• Progression to cardiogenic shock

Major guidelines:

• American Heart Association (AHA)
• European Society of Cardiology (ESC)

2️⃣ Pathophysiology of ADHF

Core Mechanisms

1. Elevated LV filling pressure → Pulmonary congestion
2. Reduced cardiac output → Hypoperfusion
3. Neurohormonal activation
• SNS activation
• RAAS activation
• Vasopressin

4. Endothelial dysfunction
5. Renal congestion → Cardiorenal syndrome

Hemodynamic Profiles 

3️⃣ Precipitating Factors 

Remember: “CHAMP”

• C – Acute Coronary Syndrome
• H – Hypertensive crisis
• A – Arrhythmia (AF common)
• M – Mechanical cause (MR, VSD)
• P – Pulmonary embolism

Others:

• Infection
• Anemia
• Thyroid disorders
• Non-compliance
• Renal failure
• NSAIDs

 Symptoms in ADHF

Signs of Left-Sided Congestion

 Signs of Right-Sided Congestion

  Signs of Hypoperfusion (Low Output State)

 Severe / Advanced ADHF (Cardiogenic Shock)

 Atypical Presentation

 Laboratory Investigations

A. Natriuretic Peptides (Cornerstone Biomarker)

• False high: CKD, elderly, sepsis
• False low: Obesity

B. Cardiac Biomarkers (Troponin)

 Troponin elevation ≠ always MI

C. Renal Function

This may indicate cardiorenal syndrome.

D. Electrolytes

Hyponatremia = Poor prognostic marker.

E. Liver Function Tests

F. Lactate

Elevated in:

• Cardiogenic shock
• Severe hypoperfusion

Lactate > 2 mmol/L = tissue hypoxia

G. Complete Blood Count

 2️⃣ ECG (Mandatory in All)

What to look for:

3️⃣ Chest X-Ray

 Early ADHF may have normal CXR.

 4️⃣ Echocardiography (Essential)

Should be done early in all new ADHF.

What to Assess:

1. LVEF

• <40% → HFrEF
• 41–49% → HFmrEF
• ≥50% → HFpEF

2. Regional Wall Motion Abnormality

→ Suggests ischemia

3. Diastolic Dysfunction

• E/e′ > 15
• LA enlargement

4. RV Function

• TAPSE ↓ in RV failure

5. Valvular Disease

• Acute MR
• AS
• TR

6. IVC Size

• Plethoric, non-collapsible → high RA pressure

5️⃣ Lung Ultrasound 

More sensitive than CXR for early congestion.

6️⃣ Hemodynamic Monitoring (Advanced Cases)

Used in:

• Cardiogenic shock
• Uncertain diagnosis
• Refractory cases

Using Pulmonary Artery Catheter:

 7️⃣ Coronary Evaluation

Indicated if:

• Suspected ACS
• High-risk ECG changes
• Elevated troponin

May require:

• Coronary angiography

 8️⃣ Additional Tests (Based on Clinical Suspicion)

Diagnostic Criteria (ESC Approach)

According to ESC, ADHF diagnosis requires:

A. Symptoms ± Signs of HF

AND

B. Elevated natriuretic peptides

AND/OR

C. Objective evidence of structural/functional cardiac abnormality

BNP Cutoffs (ESC Emergency Setting)

If below these → HF unlikely.

Elevated values support diagnosis but are not specific.

Management

1️⃣ Oxygen Therapy

• Target SpO₂ > 92%
• Avoid routine oxygen if saturation normal

2️⃣ Non-Invasive Ventilation 

CPAP/BiPAP

Benefits:

• ↓ Preload
• ↓ Afterload
• Improves oxygenation
• Reduces intubation rate

Indicated in:

• Acute pulmonary edema
• Severe dyspnea

3️⃣ Intubation (If Required)

Indications:

• Altered sensorium
• Severe hypoxia
• Exhaustion
• Cardiogenic shock

 Use caution: Positive pressure can reduce preload in hypotensive patients.

 Decongestion 

 IV Loop Diuretics (First-Line)

Drug:

Furosemide IV

Dosing Strategy:

• If chronic user: ≥ home oral dose IV equivalent

Expected Response:

• Urine output within 1–2 hours
• Relief of dyspnea

 Diuretic Resistance

If inadequate response:

1. Double dose
2. Switch to continuous infusion
3. Add thiazide (metolazone)
4. Consider ultrafiltration (selected cases)

Vasodilators (If BP > 110 mmHg)

IV Nitroglycerin

Best in:

• Hypertensive pulmonary edema
• Flash pulmonary edema

Mechanism:

• Venodilation → ↓ preload
• At higher dose → ↓ afterload

Contraindicated in:

• Hypotension
• Severe aortic stenosis

Sodium Nitroprusside

Powerful arterial + venous dilator
Used in:

• Severe afterload excess

Requires:

• ICU monitoring
• Watch for cyanide toxicity

Inotropes 

Indicated in:

• Cold profile
• Cardiogenic shock
• Low cardiac output with hypotension

Dobutamine

• β1 agonist
• ↑ contractility
• Mild vasodilation

Best for:

• Low CO with normal BP

Milrinone

• PDE-3 inhibitor
• Inotrope + vasodilator
• Good in pulmonary hypertension

Avoid in:

• Hypotension

Norepinephrine (Preferred Vasopressor)

Used in:

• Cardiogenic shock with hypotension

Mechanism:

• ↑ SVR
• Maintains perfusion pressure

 Cardiogenic Shock Protocol

If SBP < 90 + hypoperfusion:

1. Norepinephrine first-line
2. Add dobutamine if low CO persists(If pressure improves but perfusion does not → Cardiac output is still low.)
3. Consider mechanical support

  Mechanical Circulatory Support

Used when:

• Refractory shock
• Persistent hypoperfusion despite drugs

Options:

Bridge to:

• Recovery
• LVAD
• Transplant

 GDMT During Hospitalization

Continue unless contraindicated:

Important principle:
Do NOT abruptly stop beta-blockers unless shock present.

 Fluid & Sodium Management

• Sodium restriction (≤2 g/day)
• Fluid restriction (1.5–2 L/day if hyponatremia)
• Strict I/O monitoring
• Daily weights