Acute decompensated heart failure: contemporary medical management

Abstract

Hospitalizations for acute decompensated heart failure are increasing in the United States. Moreover, the prevalence of heart failure is increasing consequent to an increased number of older individuals, as well as to improvement in therapies for coronary artery disease and sudden cardiac death that have enabled patients to live longer with cardiovascular disease. The main treatment goals in the hospitalized patient with heart failure are to restore euvolemia and to minimize adverse events. Common in-hospital treatments include intravenous diuretics, vasodilators, and inotropic agents. Novel pharmaceutical agents have shown promise in the treatment of acute decompensated heart failure and may simplify the treatment and reduce the morbidity associated with the disease. This review summarizes the contemporary management of patients with acute decompensated heart failure.

Keywords: Acute disease; United States/epidemiology; aged; cardiac output, low; disease progression; diuretics; furosemide; heart failure/classification/drug therapy/mortality; hospitalization; length of stay; milrinone; morbidity/trends; relaxin; tolvaptan; ultrafiltration; vasodilator agents; ventricular dysfunction, left.

Fig. 1. Number of days from onset of worsening of selected symptoms of heart failure to hospital admission in 83 patients admitted with heart failure. Most symptoms were present 1 week before admission, which suggests that earlier outpatient intervention might reduce hospitalizations. Data from: Schiff GD, Fung S, Speroff T, McNutt RA. Decompensated heart failure: symptoms, patterns of onset, and contributing factors. Am J Med 2003;114(8):625–30. (Reproduced with permission.)

Fig. 2. Hemodynamic profiles of patients presenting with advanced heart failure, as described by a 2 × 2 table. Evaluation of clinical symptoms and signs enables the classification of a patient into a hemodynamic profile and may assist in selecting initial therapy and providing prognostic information. Although this classification scheme was developed for patients who have, predominantly, systolic dysfunction and advanced heart failure, it provides a useful construct for the evaluation of patients with ADHF as well. Modified from: Nohria A, Mielniczuk LM, Stevenson LW. Evaluation and monitoring of patients with acute heart failure syndromes. Am J Cardiol 2005;96(6A):32G–40G.

Fig. 3. Adverse events in comparison of short-term milrinone infusion with standard medical therapy, from the OPTIME-CHF trial. fib = fibrillation; MI = myocardial infarction Reproduced with permission from: Cuffe MS, Califf RM, Adams KF Jr, Benza R, Bourge R, Colucci WS, et al. Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial. JAMA 2002;287(12):1541–7.

Fig. 4. Adenosine antagonists are being investigated as diuretics that improve renal function. In 1 study, the adenosine antagonist BG9719 in combination with furosemide increased urine output while preserving the glomerular filtration rate (GFR). Reproduced with permission from: Gottlieb SS, Brater DC, Thomas I, Havranek E, Bourge R, Goldman S, et al. BG9719 (CVT-124), an A1 adenosine receptor antagonist, protects against the decline in renal function observed with diuretic therapy [published erratum appears in Circulation 2002;106(13):1743]. Circulation 2002;105(11):1348–53.