Update on the Management of Acute Decompensated Heart Failure

Valvular, Myocardial, Pericardial, and Cardiopulmonary Diseases (Patrick O’Gara and Akshay Desai, Section Editors)

Opinion statement

Treatment goals of acute decompensated heart failure are to decrease congestion, afterload, and neurohormonal activation in order to improve hemodynamics and symptoms and, perhaps, reduce in-hospital events, re-hospitalizations, and mortality while avoiding toxicities of therapy such as hypotension, arrhythmias, and renal dysfunction. Relief of congestion through intravenous loop diuretics is a mainstay of therapy. In cases where diuretics are not effective, ultrafiltration may be used to achieve euvolemia. Beta-blockers should be continued or reduced in dose at admission but should not typically be held. In patients with normotensive or hypertensive heart failure, afterload reduction with vasodilators should be instituted at presentation. Choice of a particular agent such as nitroglycerin, nitroprusside, or nesiritide depends on patient characteristics such as presence of ischemia, degree of congestion, and renal function. Nitroprusside may be preferable in patients with congestion and low cardiac output, but with caution in patients with significant hypotension. Intravenous inotropes/inodilators, such as dobutamine and milrinone, should be limited to hypotensive patients with evidence of poor tissue perfusion. Milrinone may be preferable in patients who have significant pulmonary venous hypertension. In patients who do not respond to initial medical therapy and who are candidates for either cardiac transplantation or destination left ventricular assist device, mechanical circulatory support should be considered early, prior to the development of end-organ damage.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics--2011 update: a report from the American Heart Association. Circulation. 2011;123(4):e18–e209.PubMedCrossRefGoogle Scholar
  2. 2.
    ADHERE Scientific Advisory Committee. Acute Decompensated Heart Failure National Registry (ADHERE®) Core Module Q1 2006 Final Cumulative National Benchmark Report: Scios, Inc.2006 July. www.adhereregistry.com; accessed February 2009.
  3. 3.•
    Massie BM, O’Connor CM, Metra M, et al. Rolofylline, an adenosine A1-receptor antagonist, in acute heart failure. N Engl J Med. 2010;363(15):1419–28.PubMedCrossRefGoogle Scholar
  4. 4.
    McMurray JJ, Teerlink JR, Cotter G, et al. Effects of tezosentan on symptoms and clinical outcomes in patients with acute heart failure: the VERITAS randomized controlled trials. JAMA. 2007;298(17):2009–19.PubMedCrossRefGoogle Scholar
  5. 5.
    Heart Failure Society of America. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail. 2010;16(6):e1–e194.CrossRefGoogle Scholar
  6. 6.
    Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur Heart J. 2008;29(19):2388–442.PubMedCrossRefGoogle Scholar
  7. 7.
    Gheorghiade M, Abraham WT, Albert NM, et al. Systolic blood pressure at admission, clinical characteristics, and outcomes in patients hospitalized with acute heart failure. JAMA. 2006;296(18):2217–26.PubMedCrossRefGoogle Scholar
  8. 8.••
    Felker GM, Lee KL, Bull DA, et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med. 2011;364(9):797–805.PubMedCrossRefGoogle Scholar
  9. 9.
    Costanzo MR, Guglin ME, Saltzberg MT, et al. Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure. J Am Coll Cardiol. 2007;49(6):675–83.PubMedCrossRefGoogle Scholar
  10. 10.
    Costanzo MR, Saltzberg MT, Jessup M, et al. Ultrafiltration is associated with fewer rehospitalizations than continuous diuretic infusion in patients with decompensated heart failure: results from UNLOAD. J Card Fail. 2010;16(4):277–84.PubMedCrossRefGoogle Scholar
  11. 11.
    Konstam MA, Gheorghiade M, Burnett Jr JC, et al. Effects of oral tolvaptan in patients hospitalized for worsening heart failure: the EVEREST Outcome Trial. JAMA. 2007;297(12):1319–31.PubMedCrossRefGoogle Scholar
  12. 12.
    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
  13. 13.
    Intravenous nesiritide vs nitroglycerin for treatment of decompensated congestive heart failure: a randomized controlled trial. JAMA 2002;287(12):1531–40.Google Scholar
  14. 14.
    Sackner-Bernstein JD, Kowalski M, Fox M, Aaronson K. Short-term risk of death after treatment with nesiritide for decompensated heart failure: a pooled analysis of randomized controlled trials. JAMA. 2005;293(15):1900–5.PubMedCrossRefGoogle Scholar
  15. 15.
    Sackner-Bernstein JD, Skopicki HA, Aaronson KD. Risk of worsening renal function with nesiritide in patients with acutely decompensated heart failure. Circulation. 2005;111(12):1487–91.PubMedCrossRefGoogle Scholar
  16. 16.
    O’Connor CM, Starling RC, Hernandez AF, et al. Effect of nesiritide in patients with acute decompensated heart failure. N Engl J Med. 2011;365(1):32–43.PubMedCrossRefGoogle Scholar
  17. 17.
    Peacock FWt, Varon J, Ebrahimi R, et al. Clevidipine for severe hypertension in acute heart failure: a VELOCITY trial analysis. Congest Heart Fail. 2010;16(2):55–9.PubMedCrossRefGoogle Scholar
  18. 18.•
    Teerlink JR, Metra M, Felker GM, et al. Relaxin for the treatment of patients with acute heart failure (Pre-RELAX-AHF): a multicentre, randomised, placebo-controlled, parallel-group, dose-finding phase IIb study. Lancet. 2009;373(9673):1429–39.PubMedCrossRefGoogle Scholar
  19. 19.
    Lapp H, Mitrovic V, Franz N, et al. Cinaciguat (BAY 58–2667) improves cardiopulmonary hemodynamics in patients with acute decompensated heart failure. Circulation. 2009;119(21):2781–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Elkayam U, Tasissa G, Binanay C, et al. Use and impact of inotropes and vasodilator therapy in hospitalized patients with severe heart failure. Am Heart J. 2007;153(1):98–104.PubMedCrossRefGoogle Scholar
  21. 21.
    Hunt SA, Abraham WT, Chin MH, et al. 2009 Focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the International Society for Heart and Lung Transplantation. J Am Coll Cardiol. 2009;53(15):e1–e90.PubMedCrossRefGoogle Scholar
  22. 22.
    Thackray S, Easthaugh J, Freemantle N, Cleland JG. The effectiveness and relative effectiveness of intravenous inotropic drugs acting through the adrenergic pathway in patients with heart failure-a meta-regression analysis. Eur J Heart Fail. 2002;4(4):515–29.PubMedCrossRefGoogle Scholar
  23. 23.••
    Mebazaa A, Parissis J, Porcher R, et al. Short-term survival by treatment among patients hospitalized with acute heart failure: the global ALARM-HF registry using propensity scoring methods. Intensive Care Med. 2011;37:290–301.PubMedCrossRefGoogle Scholar
  24. 24.
    Mebazaa A, Nieminen MS, Packer M, et al. Levosimendan vs dobutamine for patients with acute decompensated heart failure: the SURVIVE Randomized Trial. JAMA. 2007;297(17):1883–91.PubMedCrossRefGoogle Scholar
  25. 25.•
    Malik FI, Hartman JJ, Elias KA, et al. Cardiac myosin activation: a potential therapeutic approach for systolic heart failure. Science. 2011;331(6023):1439–43.PubMedCrossRefGoogle Scholar
  26. 26.
    Teerlink JR. A novel approach to improve cardiac performance: cardiac myosin activators. Heart Fail Rev. 2009;14(4):289–98.PubMedCrossRefGoogle Scholar
  27. 27.
    Teerlink JR, Clarke CP, Saikali KG, et al. Dose-dependent augmentation of cardiac systolic function with the selective cardiac myosin activator, omecamtiv mecarbil: a first-in-man study. Lancet. 2011;378(9792):667–75.PubMedCrossRefGoogle Scholar
  28. 28.
    Cleland JG, Teerlink JR, Senior R, et al. The effects of the cardiac myosin activator, omecamtiv mecarbil, on cardiac function in systolic heart failure: a double-blind, placebo-controlled, crossover, dose-ranging phase 2 trial. Lancet. 2011;378(9792):676–83.PubMedCrossRefGoogle Scholar
  29. 29.
    Switzer CH, Flores-Santana W, Mancardi D, et al. The emergence of nitroxyl (HNO) as a pharmacological agent. Biochim Biophys Acta. 2009;1787(7):835–40.PubMedCrossRefGoogle Scholar
  30. 30.
    Peacock WF, Costanzo MR, De Marco T, et al. Impact of intravenous loop diuretics on outcomes of patients hospitalized with acute decompensated heart failure: insights from the ADHERE registry. Cardiology. 2009;113(1):12–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Elkayam U, Ng TMH, Hatamizadeh P, et al. Renal vasodilatory action of dopamine in patients with heart failure: magnitude of effect and site of action. Circulation. 2008;117:200–5.PubMedCrossRefGoogle Scholar
  32. 32.
    Giamouzis G, Butler J, Starling RC, et al. Impact of dopamine infusion on renal function in hospitalized heart failure patients: results of the dopamine in acute decompensated heart failure (DAD-HF) Trial. Journal of Cardiac Failure. 2010;16:922–30.PubMedCrossRefGoogle Scholar
  33. 33.
    Friedrich JO, Adhikari N, Herridge MS, Beyene J. Meta-analysis: low dose-dopamine increases urine output but does not prevent renal dysfunction or death. Ann Intern Med. 2005;142:510–24.PubMedGoogle Scholar
  34. 34.
    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):1872–6.PubMedCrossRefGoogle Scholar
  35. 35.
    Despas F, Trouillet C, Franchitto N, et al. Levosimedan improves hemodynamics functions without sympathetic activation in severe heart failure patients: direct evidence from sympathetic neural recording. Acute Card Care. 2010;12(1):25–30.PubMedCrossRefGoogle Scholar
  36. 36.
    Cleland JG, Freemantle N, Coletta AP, Clark AL. Clinical trials update from the American Heart Association: REPAIR-AMI, ASTAMI, JELIS, MEGA, REVIVE-II, SURVIVE, and PROACTIVE. Eur J Heart Fail. 2006;8(1):105–10.PubMedCrossRefGoogle Scholar
  37. 37.
    Bergh CH, Andersson B, Dahlstrom U, et al. Intravenous levosimendan vs. dobutamine in acute decompensated heart failure patients on beta-blockers. Eur J Heart Fail. 2010;12(4):404–10.PubMedCrossRefGoogle Scholar
  38. 38.
    de Lissovoy G, Fraeman K, Teerlink JR, et al. Hospital costs for treatment of acute heart failure: economic analysis of the REVIVE II study. Eur J Health Econ. 2010;11(2):185–93.PubMedCrossRefGoogle Scholar
  39. 39.
    Peacock WF, Hollander JE, Diercks DB, et al. Morphine and outcomes in acute decompensated heart failure: an ADHERE analysis. Emerg Med J. 2008;25(4):205–9.PubMedCrossRefGoogle Scholar
  40. 40.
    Udelson JE, McGrew FA, Flores E, et al. Multicenter, randomized, double-blind, placebo-controlled study on the effect of oral tolvaptan on left ventricular dilation and function in patients with heart failure and systolic dysfunction. J Am Coll Cardiol. 2007;49(22):2151–9.PubMedCrossRefGoogle Scholar
  41. 41.
    Mielniczuk LM, Haddad H, Davies RA. Ultrafiltration in the management of acute decompensated heart failure. Curr Opin Cardiol. 2010;25(2):155–60.PubMedCrossRefGoogle Scholar
  42. 42.
    Bradley SM, Levy WC, Veenstra DL. Cost-consequences of ultrafiltration for acute heart failure: a decision model analysis. Circ Cardiovasc Qual Outcomes. 2009;2(6):566–73.PubMedCrossRefGoogle Scholar
  43. 43.
    Patel CB, Alexander KM, Rogers JG. Mechanical circulatory support for advanced heart failure. Curr Treat Options Cardiovasc Med. 2010;12(6):549–65.PubMedCrossRefGoogle Scholar
  44. 44.
    Khan H, Metra M, Blair JE, et al. Istaroxime, a first in class new chemical entity exhibiting SERCA-2 activation and Na-K-ATPase inhibition: a new promising treatment for acute heart failure syndromes? Heart Fail Rev. 2009;14(4):277–87.PubMedCrossRefGoogle Scholar
  45. 45.
    Gheorghiade M, Blair JE, Filippatos GS, et al. Hemodynamic, echocardiographic, and neurohormonal effects of istaroxime, a novel intravenous inotropic and lusitropic agent: a randomized controlled trial in patients hospitalized with heart failure. J Am Coll Cardiol. 2008;51(23):2276–85.PubMedCrossRefGoogle Scholar
  46. 46.
    Shah SJ, Blair JE, Filippatos GS, et al. Effects of istaroxime on diastolic stiffness in acute heart failure syndromes: results from the Hemodynamic, Echocardiographic, and Neurohormonal Effects of Istaroxime, a Novel Intravenous Inotropic and Lusitropic Agent: a Randomized Controlled Trial in Patients Hospitalized with Heart Failure (HORIZON-HF) trial. Am Heart J. 2009;157(6):1035–41.PubMedCrossRefGoogle Scholar
  47. 47.
    Mitrovic V, Hernandez AF, Meyer M, Gheorghiade M. Role of guanylate cyclase modulators in decompensated heart failure. Heart Fail Rev. 2009;14(4):309–19.PubMedCrossRefGoogle Scholar
  48. 48.
    Lee CY, Chen HH, Lisy O, et al. Pharmacodynamics of a novel designer natriuretic peptide, CD-NP, in a first-in-human clinical trial in healthy subjects. J Clin Pharmacol. 2009;49(6):668–73.PubMedCrossRefGoogle Scholar
  49. 49.
    McKie PM, Sangaralingham SJ, Burnett Jr JC. CD-NP: an innovative designer natriuretic peptide activator of particulate guanylyl cyclase receptors for cardiorenal disease. Curr Heart Fail Rep. 2010;7(3):93–9.PubMedCrossRefGoogle Scholar
  50. 50.
    Mebazaa A, Parissis J, Porcher R, Gayat E, Nikolaou M, Boas FV, et al. Short-term survival by treatment among patients hospitalized with acute heart failure: the global ALARM-HF registry using propensity scoring methods. Intensive Care Medicine. 2010;37:290–301.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC (outside the USA) 2011

Authors and Affiliations

  1. 1.Section of CardiologySan Francisco Veterans Affairs Medical CenterSan FranciscoUSA
  2. 2.University of California, San FranciscoSan FranciscoUSA

Personalised recommendations