What are the causes of Acute Decompensated Heart Failure (ADHF) as per Harrison?

Causes of Acute Decompensated Heart Failure (ADHF)

The causes of ADHF can be systematically categorized into primary cardiac causes, acute precipitating factors, and non-cardiovascular precipitants, with decompensation of pre-existing chronic heart failure being the most common presentation, followed by acute coronary syndromes and medication/dietary non-adherence as the leading precipitating factors. 1

Primary Cardiac Causes

Chronic Heart Failure Decompensation

• Decompensation of pre-existing chronic heart failure (including cardiomyopathy) represents the most common underlying cause, with most hospitalizations following a gradual increase in cardiac filling pressures rather than truly "acute" events 1
• Coronary heart disease accounts for 60-70% of ADHF cases, particularly in elderly populations 1
• In younger patients, dilated cardiomyopathy, arrhythmias, congenital heart disease, and valvular disease are more frequent causes 1

Acute Coronary Syndromes

• Myocardial infarction or unstable angina with extensive ischemia and ischemic dysfunction occurs in 13-14% of decompensations 1, 2
• Mechanical complications of acute myocardial infarction (papillary muscle rupture, ventricular septal defect) 1
• Right ventricular infarction 1

Acute Valvular Pathology

• Acute valvular regurgitation from endocarditis, chordae tendinae rupture, or acute worsening of pre-existing regurgitation 1
• Severe aortic stenosis 1

Other Acute Cardiac Conditions

• Acute severe myocarditis, particularly when accompanied by conduction block or ventricular arrhythmias 1
• Cardiac tamponade 1
• Aortic dissection 1
• Post-partum cardiomyopathy 1

Acute Precipitating Factors

Medication and Dietary Non-Adherence

• Lack of compliance with medical treatment is identified as the most common precipitating factor in 42-47% of cases 1, 2
• Non-adherence to sodium and fluid restrictions 1

Hypertensive Crisis

• Uncontrolled hypertension contributes to 27% of cases and is particularly important in African Americans, women, and patients with preserved ejection fraction 1, 2
• Nearly 50% of patients admitted with ADHF have blood pressure >140/90 mmHg 1
• Abrupt discontinuation of antihypertensive therapy may precipitate decompensation 1

Arrhythmias

• Acute arrhythmias including ventricular tachycardia, ventricular fibrillation, atrial fibrillation/flutter, and other supraventricular tachycardias 1
• Atrial fibrillation has a prevalence >30% in acute heart failure patients 1, 2

Infections

• Pneumonia and septicemia are particularly common precipitants that increase metabolic demands and may add hypoxia 1
• Urinary tract infections 2
• The sepsis syndrome causes reversible myocardial depression mediated by cytokine release 1

Iatrogenic Causes

• Recent addition of negative inotropic drugs (verapamil, nifedipine, diltiazem, beta blockers) 1
• Initiation of drugs that increase sodium retention (NSAIDs, steroids, thiazolidinediones) 1

Renal Dysfunction

• Reduction in renal function can be both a consequence and contributor to decompensation 1

Other Medical Conditions

• Pulmonary embolism (patients with heart failure are hypercoagulable) 1
• Endocrine abnormalities: hyper- or hypothyroidism, diabetes mellitus 1
• Severe brain insult 1
• Anemia 1
• Asthma 1
• Post-major surgery 1

Substance Use

• Excessive alcohol consumption 1, 2
• Illicit drug abuse 1

High Output Syndromes

• Septicemia 1
• Thyrotoxicosis crisis 1
• Anemia 1
• Shunt syndromes 1
• Pheochromocytoma 1

Critical Clinical Considerations

Hemodynamic Patterns

• Up to 1 in 4 patients have mismatch between right- and left-sided filling pressures, with disproportionate elevation of right-sided pressures (particularly with tricuspid regurgitation) hindering effective decongestion 1, 2
• Disproportionate elevation of left-sided filling pressures may be under-recognized as the cause of dyspnea without jugular venous distention or edema 1

Common Pitfalls

• Most ADHF hospitalizations are not truly "acute" but follow gradual increases in cardiac filling pressures on pre-existing structural heart disease with identifiable precipitating factors 1, 2
• Initial triage must recognize patients with acute coronary syndromes requiring urgent revascularization 1
• Recent onset with accelerating hemodynamic decompensation may represent inflammatory heart disease, especially with conduction abnormalities 1