What is the current recommended management for an adult with acute decompensated heart failure, regardless of ejection fraction?

Management of Acute Decompensated Heart Failure

The cornerstone of acute decompensated heart failure management is immediate relief of congestion with intravenous loop diuretics, followed by rapid assessment of hemodynamic profile (volume status and perfusion adequacy) to guide additional therapies, while simultaneously planning early initiation or optimization of guideline-directed medical therapy for long-term mortality reduction. 1, 2

Immediate Assessment and Hemodynamic Profiling

Upon presentation, rapidly determine three critical parameters 1:

• Volume status: Assess for peripheral edema, elevated jugular venous pressure, rapid weight gain (>2 kg in 3 days), and pulmonary congestion 2
• Perfusion adequacy: Evaluate for hypotension, cool extremities, altered mental status, and end-organ dysfunction (worsening renal function) 1, 3
• Precipitating factors: Screen for acute coronary syndrome with troponins (present in up to 20% of cases), arrhythmias, medication/dietary noncompliance, infections, or uncontrolled hypertension 1

Use the "wet/dry" and "warm/cold" classification system to stratify patients into four hemodynamic profiles that predict prognosis and guide therapy 3:

• Wet-Warm (most common): Congested but adequately perfused
• Wet-Cold: Congested with hypoperfusion
• Dry-Warm: Compensated
• Dry-Cold: Hypoperfused without congestion

Obtain BNP or NT-proBNP when the diagnosis is uncertain, but interpret in clinical context rather than isolation 1

Primary Treatment: Decongestion

For all patients with fluid overload, initiate intravenous loop diuretics immediately as the mainstay of therapy 1, 3:

• Loop diuretics provide rapid symptom relief and should be started before or alongside other therapies 2
• The primary therapeutic goal is reduction of left ventricular filling pressures, which directly correlates with symptoms and predicts mortality 4, 5
• Persistently elevated left ventricular filling pressure is highly predictive of fatal decompensation and sudden death 4, 5

Implement daily weight monitoring with patient education on self-monitoring and flexible diuretic adjustment 2

Vasodilator Therapy

In patients with severe symptomatic fluid overload WITHOUT systemic hypotension, add intravenous vasodilators (nitroglycerin, nitroprusside, or nesiritide) to diuretics, or use when diuretics alone are insufficient 1:

• Vasodilators reduce pulmonary wedge pressure through balanced arterial and venous dilation 4, 5
• There is a more compelling physiologic rationale for vasodilators than inotropes, as measures of systemic perfusion and vascular resistance have not predicted clinical outcomes 4, 5
• Avoid excessive diuresis before starting vasodilators, as volume depletion can cause hypotension 2

Inotropic Support: Use Sparingly

Intravenous inotropes (dopamine, dobutamine, or milrinone) might be reasonable ONLY for patients with documented severe systolic dysfunction, low blood pressure, AND evidence of low cardiac output with inadequate organ perfusion 1:

• Do NOT use parenteral inotropes in normotensive patients without evidence of decreased organ perfusion 1
• Short-term hemodynamic benefits must be balanced against increased adverse events 3
• Routine use of inotropes should be discouraged 3

Invasive Hemodynamic Monitoring

Reserve invasive hemodynamic monitoring for carefully selected patients with persistent symptoms despite empiric therapy adjustment 1:

Consider when:

• Fluid status, perfusion, or vascular resistances remain uncertain 1
• Systolic pressure remains low or symptomatic despite initial therapy 1
• Renal function worsens with therapy 1
• Parenteral vasoactive agents are required 1
• Advanced device therapy or transplantation is being considered 1

Do NOT routinely use invasive monitoring in normotensive patients with congestion who respond symptomatically to diuretics and vasodilators 1

Refractory Congestion

Ultrafiltration is reasonable for patients with refractory congestion not responding to medical therapy 1

Revascularization for Acute Ischemia

When patients present with acute heart failure AND known or suspected acute myocardial ischemia with inadequate systemic perfusion, urgent cardiac catheterization and revascularization is reasonable where it prolongs meaningful survival 1

Early Initiation of Guideline-Directed Medical Therapy

Once hemodynamically stabilized during hospitalization, initiate or optimize quadruple guideline-directed medical therapy (GDMT) for HFrEF, which provides 73% mortality reduction over 2 years 2, 6:

The four foundational therapies 2, 6:

• ARNI (sacubitril/valsartan) as first-line (≥20% mortality reduction vs. ACE inhibitors), target 97/103 mg twice daily 2
• Evidence-based beta-blockers (bisoprolol, carvedilol, metoprolol succinate, or nebivolol) 1, 6
• Mineralocorticoid receptor antagonists (spironolactone or eplerenone) 6
• SGLT2 inhibitors (dapagliflozin or empagliflozin) regardless of diabetes status 6

Initiate all four medication classes simultaneously rather than sequentially for most rapid mortality benefit 2, 6

Critical Pitfall to Avoid

Never discontinue GDMT even if ejection fraction improves—discontinuation leads to clinical deterioration 2:

• Continue all HFrEF medications indefinitely regardless of EF improvement 2
• Asymptomatic low blood pressure should not be a barrier to GDMT initiation or maintenance 6

Post-Discharge Management

Utilize post-discharge systems of care to facilitate transition to effective outpatient care 1:

• Schedule early follow-up within 7-14 days after discharge 2
• Use forced-titration approach with medication adjustments every 1-2 weeks until target doses achieved within 2 months 2
• Implement multidisciplinary team management involving cardiologists, primary care physicians, nurses, and pharmacists 1, 2
• Provide comprehensive patient education on both conditions, daily weight monitoring, and recognition of worsening symptoms 1, 2
• Consider cardiac rehabilitation once stable, as exercise training improves exercise tolerance, quality of life, and reduces HF hospitalization rates 1, 2

Up to 25% of patients are readmitted within 30-60 days, making the early post-discharge phase a vulnerable period requiring intensive intervention 7