ACUTE DECOMPENSATED HEART FAILURE
GEN ERAL PRINCIPLES
ADHF is a heterogeneous clinical syndrome most often resulting in need for hospitalization due to conf1uence of interrelated abnormalities of decreased cardiac performance, renal dysfunction ,and alterations in vascular compliance. Admission with a diagnosis of ADHF is associated with excessive morbidity and mortality, with nearly half of these patients readmitted for management within 6 months, and a high short-term (5-8% in-hospital) and long-term mortality (20% at 1 year).
See the following table for Intravenous Therapy in Acute Decompensated Heart Failure.
Importantly, long-term aggree outcomes remain poor, with a combined incidence of cardiovascular deaths, heart failure hospital izations, myocardial infarction, strokes, or sudden death reaching 50% at 12 months after hospitalization. The management of these patients has remained difficult and principally revolves around volume control and decrease of vascular impedance while maintaining attention to end-organ perfusion (coronary and renal).
The first principle of management of these patients is ω nt的and tackle known precipitants of decompensation. Identification and man agement of medication nonadherence and use of prescribed medicines such as nonsteroidal anti-inf1ammatory drugs, cold and f1u prepara tions with cardiac stimulants, and herbal preparations, including lico rice, ginseng, and ma huang (an herbal form of ephedrine now banned in most places), are required. Aιtive infection and overt or ιovert pul monary thromboembolism should be sought, identified, and trωted when clinical clues suggest such direction. When possible, arrhythmias should be corrected by controlling heart rate or restoring sinus rhythm in patients with poorly tolerated rapid atrial fibrillation and by correcting ongoing ischemia with coronary revascularization or by correcting o旺enders such as ongoing bleeding in demand-related ischemia. A parallel step in management involves stabilization of hemodynam ics in those with instability. The routine use of a pulmonary artery catheter is not recommended and should be restricted to those who respond poorly to diuresis or experience hypotension or signs and symptoms suggestive of a low cardiaι output where therapeutic targets are unclear. Analysis of in -hospital registries has identified several.