Summary

Acute Decompensated Heart Failure (ADHF) is characterised by rapid onset or worsening of heart failure symptoms requiring urgent therapy. Presentations range from acute pulmonary oedema to cardiogenic shock. Management depends on haemodynamic profile (warm/cold, wet/dry). First-line therapy for most patients is IV diuretic therapy with oxygen and vasodilators. NIV is beneficial in acute pulmonary oedema. Inotropes are reserved for cardiogenic shock.

Key Facts

• Prevalence: 1-2% of adult population has HF; ADHF is most common HF hospitalisation
• Mortality: In-hospital 5-10%; 1-year 25-30%
• IV Furosemide: First-line diuretic (2.5x home oral dose or 40mg if naive)
• GTN: Vasodilator of choice (if SBP greater than 90)
• NIV (CPAP): Reduces intubation and mortality in pulmonary oedema
• Cardiogenic shock: Inotropes + consider mechanical support

Clinical Pearls

"Sit them up, give them oxygen, give them diuretic, give them GTN"

Wet + Warm = Diuretics + Vasodilators; Wet + Cold = Inotropes (cardiogenic shock)

Always look for and treat the precipitant — especially ACS, arrhythmia, infection

Why This Matters Clinically

ADHF is a common cause of acute medical admission and carries high mortality. Rapid clinical assessment of haemodynamic status guides therapy. Early NIV in pulmonary oedema is underused but highly effective.

Acute Pulmonary Oedema — Emergency Management

Immediate Actions:

1. Position

   • Sit patient upright
   • Legs dependent (reduces preload)

2. Oxygen

   • High-flow if SpO2 less than 94%
   • Target 94-98%

3. IV Access and Monitoring

   • Continuous SpO2, ECG
   • Insert urinary catheter

4. IV Furosemide

   • If on regular oral furosemide: Give 2.5x daily dose IV
   • If diuretic-naive: 40-80mg IV
   • Expect diuresis within 30-60 mins

5. Vasodilators (If SBP greater than 90)

   • GTN: 1-2 sprays SL, then infusion (10-200 mcg/min)
   • Reduces preload and afterload
   • Avoid if hypotensive or recent PDE5 inhibitor

6. Non-Invasive Ventilation (CPAP)

   • Indications: Hypoxia despite O2, RR greater than 25, acidosis
   • Start at 5-10 cmH2O CPAP
   • Reduces work of breathing, improves oxygenation
   • Reduces intubation rate

7. Identify and Treat Precipitant

   • ECG: ACS, arrhythmia
   • Troponin, BNP
   • Septic screen if febrile

[!WARNING] Do NOT give morphine routinely — increases mortality in ADHF. Reserve for severe distress/anxiety.

Cardiogenic Shock (Wet + Cold)

Features:

• SBP less than 90 mmHg
• Cold, clammy, mottled peripheries
• Oliguria
• Altered consciousness

Management:

• Inotropes: Dobutamine 2.5-10 mcg/kg/min OR Noradrenaline
• Reduce diuretics initially (may worsen hypotension)
• Consider mechanical support: IABP, Impella, ECMO
• ICU admission

History

Symptoms:

• Dyspnoea — especially orthopnoea, PND
• Peripheral oedema
• Fatigue
• Weight gain
• Reduced exercise tolerance

Assess Precipitant:

• Chest pain (ACS)
• Palpitations (arrhythmia)
• Fever (infection)
• Dietary indiscretion
• Medication non-compliance

Physical Examination

Congestion (Wet):

• Elevated JVP
• Peripheral oedema
• Pulmonary crackles
• S3 gallop
• Pleural effusions

Hypoperfusion (Cold):

• Cool extremities
• Mottled skin
• Confusion
• Oliguria
• Low BP, narrow pulse pressure

Other Signs:

• Hepatomegaly (right heart failure)
• Ascites
• Murmurs (valvular disease)

Killip Classification (Post-MI)

NYHA Functional Class

By Ejection Fraction

By Presentation

Acute Management Summary

IV Diuretics

• Furosemide: 2.5x oral dose IV (or 40-80mg if naive)
• Monitor urine output (target greater than 0.5 ml/kg/hr)
• If poor response: Increase dose, add thiazide (metolazone), or infusion

Vasodilators

• GTN: Infusion 10-200 mcg/min if SBP greater than 90
• Reduces preload and afterload
• Particularly useful in hypertensive HF

Inotropes (Cardiogenic Shock)

Long-Term HF Therapy (Once Stable)

HFrEF "Four Pillars":

1. ACE inhibitor or ARNI (Sacubitril/Valsartan)
2. Beta-blocker (Bisoprolol, Carvedilol)
3. MRA (Spironolactone, Eplerenone)
4. SGLT2 inhibitor (Dapagliflozin, Empagliflozin)

Additional:

• Diuretics for congestion
• Device therapy (ICD, CRT) if indicated

Mortality

Good Prognostic Factors

• Identifiable and treatable precipitant
• Preserved EF
• Good response to diuretics
• Toleration of disease-modifying therapy

Poor Prognostic Factors

• Low EF (less than 25%)
• Cardiogenic shock
• Recurrent admissions
• Poor renal function
• Hyponatraemia
• Elevated BNP despite treatment

Key Guidelines

1. NICE NG106: Chronic Heart Failure (2018) — nice.org.uk/guidance/ng106
2. ESC Guidelines for Acute and Chronic Heart Failure (2021) — European standard

Landmark Trials

3CPO (2008) — CPAP in Acute Pulmonary Oedema

• NIV reduces intubation rate
• Trend towards mortality benefit PMID: 18614508

DOSE (2011) — Diuretic Strategies

• High-dose IV furosemide safe and effective
• No difference intermittent vs continuous PMID: 21366472

DAPA-HF, EMPEROR-Reduced — SGLT2 inhibitors

• Reduce hospitalisation and CV death in HFrEF
• Now part of guideline-directed therapy

Evidence Levels

What is Heart Failure?

Heart failure means your heart is not pumping blood as well as it should. This causes fluid to build up in your body, especially your lungs and legs.

What Are the Symptoms?

• Breathlessness — especially when lying flat or at night
• Swollen ankles and legs
• Tiredness
• Weight gain from fluid

What Causes a Flare-Up?

• Eating too much salt
• Not taking your medicines
• Chest infection
• Heart rhythm problems
• Heart attack

What Happens in Hospital?

• Medicines through a drip to help remove fluid
• Oxygen if needed
• Tests to find what caused the flare-up
• Your medicines may be adjusted

How Can I Stay Well?

• Take your medicines every day
• Weigh yourself daily — report sudden weight gain
• Limit salt in your diet
• Stay active as advised
• Get your flu jab yearly
• Limit alcohol

When to Seek Help

• Increasing breathlessness
• Worsening swelling
• Weight gain greater than 2kg in 2 days
• Chest pain