Evaluation and Management of Patients with Acute Decompensated Heart Failure

Overview

Acute decompensated heart failure (ADHF) has emerged as a major public health problem over the past 2 decades.1,2 Heart failure (HF) is the leading cause of hospitalization in patients older than 65 years of age. In-hospital mortality is excessive and readmission is disturbingly common, despite advances in pharmacotherapy and device therapy for HF.3,4 The large direct costs associated with caring for the 5 million Americans who have chronic HF are largely attributable to hospitalization.5

Data from several studies have refined our understanding of the clinical characteristics of patients hospitalized with worsening HF.2,4-6 These studies demonstrate that the majority of patients hospitalized with HF have evidence of systemic hypertension on admission and commonly have preserved left ventricular ejection fraction (LVEF). Most hospitalized patients have significant volume overload, and congestive symptoms predominate. Patients with severely impaired systolic function, reduced blood pressure, and symptoms from poor end-organ perfusion are in the distinct minority. Natural history studies have shown that ADHF represents a period of high risk for patients, during which their likelihood of death and rehospitalization is significantly greater than for a comparable period of chronic, but stable HF.6

The clinical classification of patients with ADHF continues to evolve and reflects ongoing changes in our understanding of the pathophysiology of this syndrome.7 Worsening renal function, persistent neurohormonal activation, and progressive deterioration in myocardial function all seem to play a role. Decompensation also commonly occurs without a fundamental worsening of underlying cardiac structure or function. Failure to adhere to prescribed medications related to inadequate financial resources, poor adherence, and lack of education or an inadequate medical regimen may lead to hospitalization without a worsening of underlying circulatory function.

There is a paucity of controlled clinical trial data to define optimal treatment for patients with acute HF. The few trials have focused primarily on symptom relief, not outcomes, and have mainly enrolled patients with reduced LVEF who were not hypertensive. Clinical studies to determine the best care processes to achieve the multiple goals for patients admitted with ADHF are lacking. The recommendations in this section address the common therapeutic dilemmas associated with the broad group of patients with ADHF using the best available evidence from clinical research and consensus expert opinion.