Update on the Management of Acute Decompensated Heart Failure

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.