It is important to recognize Acute Decompensated Heart Failure (ADHF) as more than just simply a clinical diagnosis but rather as a condition with a wide range of possible clinical presentations. Patients presenting with ADHF typically fall into 1 of 4 recognized hemodynamic profiles that when appropriately identified, provide a particularly useful framework to guide therapy. The correct profile can be determined based on two clinical parameters: perfusion status and congestion. 

The assessment of a patient suspected to be in ADHF starts with a good history & exam. Signs of poor perfusion include cool extremities, fatigue, altered mental status and low urine output. Signs of congestion include Crackles/Rales on auscultation, JVD, Orthopnea/PND and Peripheral Edema. Some exam findings may be more specific rather than sensitive making the diagnosis challenging. Imaging and more importantly, bedside ultrasound are excellent at evaluating hemodynamics and cardiac function (“the squeeze”) along with presence of pulmonary edema (“B-lines).  ECG is vital while lab markers such as BNP/NT-proBNP and Troponin may be elevated and helpful in establishing a diagnosis. 

Adequate perfusion without congestion (Warm & Dry) is the treatment goal with emphasis placed on prevention. Most patients, however, are adequately perfused but congested on presentation (“Warm & Wet”). They may benefit from LV afterload reduction (Vasodilators) which augment forward flow to the kidneys where excess volume can then be excreted using diuretics. The poorly perfused and non-congested profile (“Cold & Dry”) usually results from the overdiuresis of a Wet & Warm patient causing hypovolemia needing a little fluid. This is not uncommon and can be prevented by adjusting the dose and/or transitioning to oral therapy when our patients have achieved negative fluid balance and are clinically improved. Poorly perfused and congested (“Cold & Wet”) is essentially Cardiogenic Shock. These patients need inotrope therapy and afterload reduction. Cardiac cath if acute coronary syndrome is the determined cause and perhaps even mechanical support (Balloon pump, Impella, LVAD, ECMO).   “Warm & Dry” is the treatment goal with emphasis then placed on prevention.

#diagnosis #differential #algorithm #management #cardiology #treatment #table #foamed #heartfailure #chf #criticalcare #icu #clinical #pharmacology