Acute Decompensated Heart Failure

  • Andrew D. M. Grant
  • Michael A. Hanna
  • Mazen A. HannaEmail author
Part of the Contemporary Cardiology book series (CONCARD)


Heart failure is a common condition associated with significant morbidity and mortality. Acute decompensated heart failure (ADHF) is the leading cause of hospitalization among elderly patients in the USA. The hemodynamic categorization of patients with ADHF is based on the intracardiac filling pressures and the adequacy of cardiac output. Much of the information required to assess these patients can be derived from the clinical examination. Noninvasive hemodynamic assessment with Doppler echocardiography is helpful in the management of heart failure patients and may provide important information at the time of acute decompensation. Right heart catheterization with placement of a pulmonary artery catheter is generally reserved for patients in whom hemodynamics remain uncertain despite optimal clinical and noninvasive evaluation. The primary goal of treatment is to relieve congestion rather than increasing cardiac output.


Fatigue Norepinephrine Cardiomyopathy Digoxin Vasopressin 


  1. 1.
    Benjamin EJ, Blaha MH, Chiuve SE, et al. Heart disease and stroke statistics – 2017 update: a report from the American Heart Association. Circulation. 2017;135(10):e146–603.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Kupari M, Lindroos M, Iivanainen AM, et al. Congestive heart failure in old age: prevalence, mechanisms and 4–year prognosis in the Helsinki Ageing Study. J Intern Med. 1997;241:387–94.PubMedCrossRefGoogle Scholar
  3. 3.
    Owan TE, Hodge DO, Herges RM, et al. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med. 2006;355:251–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute heart failure of the European Society of Cardiology (ESC). European Heart J. 2016;37:2129–200.CrossRefGoogle Scholar
  5. 5.
    Fonarow GC, Adams KF, Abraham WT, et al. Risk stratification for in-hospital mortality in acutely decompensated heart failure. JAMA. 2005;293:572–80.PubMedCrossRefGoogle Scholar
  6. 6.
    Bergethon KE, Ju C, DeVore AD, et al. Trends in 30-day readmission rates for patients hospitalized with heart failure: findings from the GWTG-HF registry. Circ Heart Fail. 2016;9(6):e002594.PubMedCrossRefGoogle Scholar
  7. 7.
    Drazner MH, Hamilton MA, Fonarow GC, et al. Relationship between right and left-sided filling pressures in 1000 patients with advanced heart failure. J Heart Lung Transplant. 1999;18:1126–32.PubMedCrossRefGoogle Scholar
  8. 8.
    Drazner MH, Prasad A, Ayers C, et al. The relationship of right- and left-sided filling pressures in patients with heart failure and preserved ejection fraction. Circ Heart Fail. 2010;3(2):202–6.PubMedPubMedCentralCrossRefGoogle Scholar
  9. 9.
    Campbell P, Drazner MH, Kato M, et al. Mismatch if right- and left-sided filling pressures in chronic heart failure. J Card Fail. 2011;17(7):561–8.PubMedCrossRefGoogle Scholar
  10. 10.
    Drazner MH, Brown RN, Kaiser PA, et al. Relationship of right- and left-sided filling pressures in patients with advanced heart failure: a 14-year multi-institutional analysis. J Heart Lung Transplant. 2012;31(1):67–72.PubMedCrossRefGoogle Scholar
  11. 11.
    Stevenson LW, Perloff JK. The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. JAMA. 1989;261:884–8.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Drazner MH, Hellkamp AS, Leier CV, et al. Value of clinician assessment of hemodynamics in advanced heart failure: the ESCAPE trial. Circ Heart Fail. 2008;1:170–7.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    From AM, Lam CS, Pitta SR, et al. Bedside assessment of cardiac hemodynamics: the impact of noninvasive testing and examiner experience. Am J Med. 2011;124(11):1051–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. JACC. 2013;62(16):e147–239.PubMedCrossRefGoogle Scholar
  15. 15.
    Nagueh SF, Bhatt R, Vivo RP, Krim SR, Sarvari SI, Russell K, Edvardsen T, Smiseth OA, Estep JD. Echocardiographic evaluation of hemodynamics in patients with decompensated systolic heart failure. Circ Cardiovasc Imaging. 2011;4(3):220–7.PubMedCrossRefGoogle Scholar
  16. 16.
    Rudski LG, Wyman WL, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, Solomon SD, Louie EK, Schiller NB. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr. 2010;23:685–713.PubMedCrossRefGoogle Scholar
  17. 17.
    Ommen SR, Nishimura RA, Appleton CP, Miller FA, Oh JK, Redfield MM, Tajik AJ. Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: a comparative simultaneous Doppler-catheterization study. Circulation. 2000;102:1788–94.PubMedCrossRefGoogle Scholar
  18. 18.
    Andersen OS, Smiseth OA, Dokainish H, et al. Estimating left ventricular filling pressure by echocardiography. JACC. 2017;69(15):1937–48.PubMedCrossRefGoogle Scholar
  19. 19.
    Mullens W, Borowski AG, Curtin RJ, Thomas JD, Tang WH. Tissue Doppler imaging in the estimation of intracardiac filling pressures in decompensated patients with advanced systolic heart failure. Circulation. 2009;119:62–70.PubMedCrossRefGoogle Scholar
  20. 20.
    Armstron WF, Ryan T, editors. Feigenbaum’s echocardiography. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2009.Google Scholar
  21. 21.
    Binanay C, Califf RM, Hasselblad V, O’Connor CM, Shah MR, Sopko G, et al. Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial. JAMA. 2005;294(13):1625–33.PubMedCrossRefGoogle Scholar
  22. 22.
    Lindenfeld J, Albert NM, Bochmen JP, et al. HFSA 2010 comprehensive heart failure practice guideline. J Card Fail. 2010;16:e1–194.PubMedCrossRefGoogle Scholar
  23. 23.
    Adamson PB, Abraham WT, Bourge RC, et al. Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: a randomized controlled trial. Lancet. 2011;377:658–66.PubMedCrossRefGoogle Scholar
  24. 24.
    Liang KV, Hiniker AR, Williams AW, et al. Use of a novel ultrafiltration device as a treatment strategy for diuretic resistant, refractory heart failure: initial clinical experience in a single center. J Cardiol Fail. 1996;12(9):707–14.CrossRefGoogle Scholar
  25. 25.
    Bart BA, Goldsmith SR, Lee KL, et al. Ultrafiltration in decompensated heart failure with cardiorenal syndrome. N Engl J Med. 2012;367:2296–304.PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    Stevenson L, Belili D, Grover-McKay M, et al. Effects of afterload reduction (diuretics and vasodilators) on left ventricular volume and mitral regurgitation in severe congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 1987;60:654–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Rosario LB, Stevenson LW, Soloman SD, et al. The mechanism of decrease in dynamic mitral regurgitation during heart failure treatment: importance of reduction in the regurgitant orifice size. J Am Coll Cardiol. 1998;32:1819–24.PubMedCrossRefGoogle Scholar
  28. 28.
    Palardy M, Stevenson LW, Tasissa G, et al. Reduction in mitral regurgitation during therapy guided by measured filling pressures in the ESCAPE trial. Circ Heart Fail. 2009;2:181–8.PubMedPubMedCentralCrossRefGoogle Scholar
  29. 29.
    Mullens W, Abrahams Z, Francis GS, et al. Sodium nitroprusside for advanced low-output heart failure. J Am Coll Cardiol. 2008;52(3):200–7.PubMedCrossRefGoogle Scholar
  30. 30.
    Opasich C, Cioffi G, Gualco A. Nitroprusside in decompensated heart failure: what should a clinician really know? Curr Heart Fail Rep. 2009;6(3):182–90.PubMedCrossRefGoogle Scholar
  31. 31.
    Mullens W, Abrahams Z, Francis GS, et al. Usefulness of isosorbide dinitrate and hydralazine as add-on therapy in patients discharged for advanced decompensated heart failure. Am J Cardiol. 2009;103:113–9.CrossRefGoogle Scholar
  32. 32.
    Cuffe MS, Calif RM, Adams KF Jr, et al. Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial. JAMA. 2002;287:1541–7.PubMedCrossRefGoogle Scholar
  33. 33.
    Jennings DL, Thompson ML. Use of combination therapy with a beta-blocker and milrinone in patients with advanced heart failure. Ann Pharmacother. 2009;43(11):172–1876.CrossRefGoogle Scholar
  34. 34.
    Tsvetkova T, Feguson D, Abraham WT, et al. Comparative hemodynamic effects of milrinone and dobutamine in heart failure patients treated chronically with carvedilol. J Card Fail. 1998;4(Suppl 1):36.CrossRefGoogle Scholar
  35. 35.
    Stevenson LW, Tillisch JH. Maintenance of cardiac output with normal filling pressures in patients with dilated heart failure. Circulation. 1986;74:1303–8.PubMedCrossRefGoogle Scholar
  36. 36.
    Mullens W, Abrahams Z, Francis GS, et al. Importance of venous congestion for worsening of renal function in advanced decompensated heart failure. J Am Coll Cardiol. 2009;53:589–96.PubMedPubMedCentralCrossRefGoogle Scholar
  37. 37.
    Winton FR. The influence of venous pressure on the isolated mammalian kidney. J Physiol. 1931;72(1):49–61.PubMedPubMedCentralCrossRefGoogle Scholar
  38. 38.
    Firth JD, Raine AE, Ledingham JG. Raised venous pressure: a direct cause of renal sodium retention in oedema? Lancet. 1988;1(8593):1033–5.PubMedCrossRefGoogle Scholar
  39. 39.
    Kendrick AH, West J, Papouchado M, et al. Direct Fick cardiac output: are assumed values of oxygen consumption acceptable? Eur Heart J. 1988;9:337–42.PubMedCrossRefGoogle Scholar
  40. 40.
    Steimle AE, Stevenson LW, Chelimsky-Fallick C, et al. Sustained hemodynamic efficacy of therapy tailored to reduce filling pressures in survivors with advanced heart failure. Circulation. 1997;96:1165–72.PubMedCrossRefGoogle Scholar
  41. 41.
    McHugh TJ, Forrester JS, Adler L, Zion D, Swan HJC. Pulmonary vascular congestion in acute myocardial infarction: hemodynamic and radiologic correlations. Ann Intern Med. 1972;76:29–33.PubMedCrossRefGoogle Scholar
  42. 42.
    Bergstra A, Svilaas T, van Veldhuisen DJ, van den Heuvel AF, van der Horst IC, Zijlstra F. Haemodynamic patterns in ST-elevation myocardial infarction: incidence and correlates of elevated filling pressures. Neth Heart J. 2007;15(3):95–9.PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    Forrester JS, Diamond G, Chatterjee K, Swan HJC. Medical therapy of acute myocardial infarction by application of hemodynamic subsets. N Engl J Med. 1976;295:1361.CrossRefGoogle Scholar
  44. 44.
    Menon V, White H, LeJemtel T, Webb JG, Sleeper LA, Hochman JS. The clinical profile of patients with suspected cardiogenic shock due to predominant left ventricular failure: a report from the SHOCK trial registry. J Am Coll Cardiol. 2000;36:1071–6.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Andrew D. M. Grant
    • 1
  • Michael A. Hanna
    • 2
  • Mazen A. Hanna
    • 2
    Email author
  1. 1.Libin Cardiovascular InstituteCalgaryCanada
  2. 2.Cleveland ClinicClevelandUSA

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