Description

Acute decompensated heart failure (ADHF) is a heterogenous group of related syndromes with new-onset or recurrence of cardiac pump function impairment. ADHF may be due to complications arising from the pericardium, myocardium, endocardium, or the heart valves. This leads to a wide variety of symptoms that are secondary to pulmonary congestion with elevated left atrial pressure, excessive fluid accumulation and reduction in cardiac output. ADHF can be a new diagnosis or represent worsening of preexisting chronic heart failure (HF). A number of terms have been used to describe this pathology including acute HF, acute HF syndrome, as well as acute decompensation of chronic HF.

Epidemiology

Incidence

• Incidence, prevalence, and costs of HF are discussed in the chapter “Heart Failure: Chronic.”
• 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 those >65 years of age, responsible for >1 million annual hospitalizations.
• About half of people who have HF die within 5 years of diagnosis. 90% of patients who have HF die within 10 years. Newer studies have cited a 37% mortality rate within 1 year in the elderly population.

Etiology and Pathophysiology

• Two potential pathophysiologic conditions lead to the clinical findings of HF, namely systolic and/or diastolic heart dysfunction. See “Heart Failure: Chronic.” Systolic dysfunction: an inotropic abnormality, and diastolic dysfunction: a compliance abnormality
  • The terms HF with reduced, midrange, preserved, or improved LVEF (HFrEF, HFmrEF, HFpEF, and HFimpEF respectively) have been adopted recently.
  • Recent American HF guidelines have also described three clinical profiles of patients with ADHF that take into account the patient’s clinical manifestations, hemodynamics, and systemic perfusion:
    • Patients with volume overload: evidenced by pulmonary and/or systemic congestion and often triggered by an acute hypertensive crisis
    • Patients with depression of cardiac output: evidenced by hypotension, renal hypoperfusion, and/or shock
    • Patients with signs and symptoms of both volume overload and shock
• ADHF can result from the following conditions:
  • Myocardial disease: exacerbation of preexisting chronic HF heralded by noncompliance or infection or some other acute trigger, such as coronary artery disease (CAD), MI, 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
  • Arrhythmias: atrial fibrillation, tachyarrhythmias, high-grade heart block, bradyarrhythmias

Genetics
See “Heart Failure: Chronic.”

Risk Factors

See “Heart Failure: Chronic.”

General Prevention

See “Heart Failure: Chronic.”

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.