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Acute Decompensated Heart Failure

Key considerations: Cardiogenic shock, Acute MI as precipitant, Acute valvular emergency (MR, AR)

Cannot miss

  • Cardiogenic shock
  • Acute MI as precipitant
  • Acute valvular emergency (MR, AR)
  • Aortic dissection

Likely diagnoses

  • Volume overload from dietary/medication non-adherence
  • Uncontrolled atrial fibrillation
  • Infection/sepsis as trigger
  • Renal dysfunction
  • New-onset cardiomyopathy

Red flags

  • SBP <90 (cardiogenic shock)
  • Respiratory distress requiring BiPAP/intubation
  • Altered mental status
  • New murmur suggesting acute valvular pathology

Workup

  • history: HF history — EF, medications, previous admissions; Medication adherence, dietary sodium intake; Weight gain timeline; Triggers: infection, arrhythmia, ischemia; exam: JVP elevation; Pulmonary crackles/rales; S3 gallop; Peripheral edema, hepatomegaly; Cool extremities (low output) vs warm (high output); labs: BNP or NT-proBNP; Troponin (rule out acute MI as trigger); BMP (renal function, electrolytes); CBC; TSH if new-onset HF; Hepatic function panel; imaging: CXR (pulmonary edema, pleural effusions, cardiomegaly); Echocardiogram (EF, valve function, wall motion); CT angiography if PE suspected; bedside: Point-of-care US: B-lines (pulmonary edema), IVC plethora, EF estimate, pleural effusion

Management

  • immediate: Upright positioning; IV furosemide (start at 1-2.5x home oral dose, give IV); Nitroglycerin drip if SBP >100 (start 10-20 mcg/min, titrate); BiPAP for respiratory distress; Do NOT give fluids if volume overloaded; general: Daily weights, strict I/O; Sodium restriction <2g/day; Fluid restriction 1.5-2L/day if hyponatremic; Continue GDMT unless contraindicated (ACEi/ARB/ARNI, beta-blocker, MRA, SGLT2i); specific: diagnosis: Cardiogenic Shock; steps: Inotropes: dobutamine or milrinone; Consider vasopressors if MAP inadequate; Cardiology/heart failure consult; Evaluate for mechanical support (IABP, Impella); diagnosis: Flash Pulmonary Edema; steps: Nitroglycerin drip (aggressive dosing); BiPAP/CPAP; IV furosemide; Identify trigger (ACS, arrhythmia, renal artery stenosis)

Disposition

  • admit: All acute decompensated HF; New-onset HF requiring workup; Hemodynamic instability or respiratory distress; discharge: Compensated on oral diuretics after adequate diuresis; Optimize GDMT before discharge; Close follow-up within 7 days; consults: Cardiology/HF for new diagnosis, cardiogenic shock, advanced therapies; Cardiac surgery if acute valvular pathology

Clinical pearls

  • BNP >400 or NT-proBNP >900 strongly suggests HF; <100/<300 virtually excludes it
  • Cold and wet = worst prognosis — needs inotropes + diuresis
  • Never discontinue beta-blocker during admission unless cardiogenic shock — just hold dose escalation
  • SGLT2 inhibitors (dapagliflozin, empagliflozin) now standard in HFrEF AND HFpEF

Source and review

  • AHA/ACC/HFSA 2022 HF Guidelines. Last reviewed: 2024-11-01