Precipitants of Acute Decompensated Heart Failure

Common Less Common

Medical / dietary noncompliance Peripartum cardiomyopathy
Acute myocardial infarction Acute myocarditis
Hypertensive crisis Infective endocarditis
Arrhythmias Valvular heart disease
Sepsis Cardiac tamponade
Anemia Thyrotoxicosis

Algorithmic Approach to Acute Decompensated Heart Failure

Acute decompensated
heart failure

No
Yes
Pulseless or breathless ? BLS / ACLS

No
Yes Consider analgesics or
Pain or distress ?
sedatives to reduce
sympathetic drive
No

Hypoxemia ? Yes Increase FIO2 : consider

BIPAP (or elective
No intubation)

Yes
Arrhythmia ? Rate and rhythm control
(e.g., pacing, DCCV,
No amiodarone)
Yes
Adequate BP (MAP Vasodilators +/- diuretics if
>65) ? volume overload

No

Hypovolemia ? Yes Volume resuscitation

 No

Signs of hypoperfusion ?
(e.g., metabolic acidosis, Yes
Inotropes +/- IABP
low SVO2)

No

Frequent monitoring,
consider PA catheter if
patient remains unstable

BLS / ACLS, basic life support / advance cardiac life support, BiPAP, bilevel
positive airway pressure, DCCV, direct current cardioversion, BP, blood pressure,
MAP, mean arterial ppressure, IABP, intra aortic balloon pump, PA, pulmonary
artery, SVO2, venous oxygen saturation.

ADHF Therapies by Clinical Presentation (Forrester Classification)

Class I : normal Class II
Normal or high
Rx : chronic HF therapy Rx : diuretics, vasodilators
Cardiac
Index CI 2.2 Pulmonary
(tissue Class III : Class IV : edema
perfusion) Hypovolemic shock Cardiogenic shock
Low
Rx : volume repletion Normal BP : vasodilators
low BP : inotropes, pressors

Low High

PCWP 18
Pulmonary capillary wedge pressure
HF, heart failure, Rx, therapy, CI, cardiac index, BP, blood pressure, PCWP,
pulmonary capillary wedge pressure
Diuretics for Acute Decompensated Heart Failure
Severity of Diuretics Dose Comments
Volume Overload
Mild to moderate Furosemide 20 – 40 mg PO or Follow Na+ and
IV K+
Severe Furosemide 40 – 120 mg IV, Up to very 6 hr for
or IV drip at 2 – bolus dosing
20 mg/hr
Refractory to loop Add metolazone 2,5 – 5 mg PO Most helpful when
diuretics 30 min prior to CrCl <30 ml/min
each furosemide
dose
Refractory to Consider inotrope (dobutamine) if renal perfusion is
combination of inadequate.
loop and thiazide Consider renal replacement therapy if renal failure (HD or
diuretics CVVHDF).
PO, by mouth, IV, intravenously, CrCl, creatinine clearance, HD, hemodialysis,
CVVHDF, continuous venovenous hemodiafiltration

Vasodilators (all have potential for causing hypotension)

Indication Vasodilator Dose (mcg/min) Comments
ADHF Nitroglycerin 10 – 200 Headache, tachyphylaxis
ADHF Nesiritide 0,01 – 0,03 Use bolus dosing with
caution
Hypertensive Nitroprusside 0,5 - 5 Isocyanate toxicity
crisis
ADHF, acute decompensated heart failure
Inotropic Agents and Vasopressors
Drug Class Dose Comments
(mcg/kg/min)
Dobutamine Inotrope 2,5 – 10 First line for ADHF
Milrinone Inotrope / vasodilator 0,25 – 0,75 Useful with beta-
blockade
Dopamine Inotrope / vasopressor 5 – 5,0 Relatively weak
agonist
Epinephrine Inotrope / vasopressor 0,05 – 0,5 If refractory to
dobutamine
Norepinephrine Vasopressor 0,05 - 1 More appropriate for
sepsis
ADHF, acute decompensated heart failure