Heart Failure, Acutely Decompensated
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Acute decompensated heart failure (ADHF) is a rapid-onset cardiac pump function impairment, structurally or functionally, resulting in inefficient perfusion, yielding symptoms due to excessive fluid accumulation and due to reduction in cardiac output. ADHF can be a new diagnosis or worsening of preexisting chronic HF.
- HF hospitalization places a major strain on health care resources, and medicare spends more to diagnose and treat HF than any other medical condition. HF is the most common cause of admission and readmission in the United States. In 2012, the total cost of HF was $30.7 billion. By 2030, total cost will increase 127% to $69.7 billion. In the United States, there are 915,000 new cases annually. HF is the primary cause of >55,000 deaths each year and a contributing factor in >280,000 deaths.
- >1 million hospital discharges/year, unchanged from 2000 to 2010, and about half of people who have HF die within 5 years of diagnosis. One in nine deaths has HF mentioned on the death certificate.
- ~6.5 million people over the age of 20 years in the United States carry an HF diagnosis; prevalence is expected to increase 46% from 2012 to 2030 resulting in >8 million cases in patients >18 years of age.
- HF is primarily a disease of the elderly; 75% of hospital admissions for HF are in persons >65 years of age.
- African Americans have the highest risk of developing HF, followed by Hispanics, Whites, and Chinese Americans, which reflects differences in prevalence of hypertension (HTN), DM, and socioeconomic status.
Etiology and Pathophysiology
- Two potential pathophysiologic conditions lead to the clinical findings of ADHF, namely systolic and/or diastolic heart dysfunction.
- Systolic dysfunction: an inotropic abnormality, due to myocardial infarction (MI) or dilated or ischemic cardiomyopathy (CM), resulting in diminished systolic emptying (ejection fraction <45%)
- Diastolic dysfunction: a compliance abnormality, due to hypertensive CM, in which ventricular relaxation is impaired (ejection fraction >45%)
- In attempt to adopt a more pragmatic approach, one that has been accepted by both the European and American HF guidelines, the terms HF with reduced, mid-range, or preserved LVEF (HFrEF, heart failure with mid-range ejection fraction [HFmrEF] and HFpEF, respectively) have been adopted recently.
- ADHF can be caused by the following conditions:
- Myocardial disease:
- Exacerbation of chronic HF heralded by noncompliance, infection; any of the following as cause of new HF or exacerbation: coronary artery disease (CAD), MI (especially new-onset ADHF), toxic damage, immune-mediated and inflammatory damage, infiltrative diseases, metabolic derangements, and genetic abnormalities
- Abnormal loading conditions
- HTN, valvular and myocardial structural defects, pericardial and endomyocardial pathologies, high output states, volume overload
- Arrhythmia: atrial fibrillation, tachyarrhythmias, high-grade heart block, bradyarrhythmias
- Myocardial disease:
Familial CM is a predisposition to development of HF (rare).
- CAD and MI: RR 8.1
- Diabetes mellitus: RR 1.9
- Cigarette smoking: RR 1.6
- Valvular heart disease: RR: 1.5
- HTN, systemic or pulmonary: RR 1.4
- Dietary sodium intake: RR 1.4
- Obesity: RR 1.3
Mortality declines have been attributed to treating HF risk factors (see above), and implementation of ACE inhibitors, β-blockers, coronary revascularization, implantable cardioverter-defibrillators, and cardiac resynchronization strategies in patients.
- B-type natriuretic peptide (BNP) screening, in conjunction with guideline-directed management/therapies, is recommended to aid in prevention of new onset HF and in development of left ventricular (LV) dysfunction in existing HF.
Commonly Associated Conditions
- Dysrhythmia followed by pump failure is the leading cause of death in ADHF. Most patients have >5 comorbidities (especially CAD, chronic kidney disease, and diabetes) and take >5 medications.
- Cardiogenic shock