Heart Failure, Acutely Decompensated

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DESCRIPTION

Acute decompensated heart failure (ADHF) is a clinical syndrome of worsened signs and symptoms of heart failure (HF). It is a heterogenous group of syndromes presenting with different phenotypes. The worsened symptoms of ADHF are due to a rise in cardiac filling pressures. This can be due to worsening dysfunction of the myocardium or heart valves; however, it can also arise from complications related to the pericardium or endocardium. The pathophysiology is characterized by either impaired ventricular filling or decreased ejection of blood resulting in pulmonary vascular and/or systemic venous congestion. In severe cases, it can cause tissue hypoperfusion and present as cardiogenic shock. ADHF can be a new diagnosis or represent worsening of preexisting HF. A number of terms have been used to describe this pathology including acute HF and acute decompensation of chronic HF.

EPIDEMIOLOGY

Incidence

See “Heart Failure, Chronic.” HF is one of the most common causes of admission and readmission in the United States in those >65 years of age, responsible for >1 million annual hospitalizations.

Prevalence

HF is primarily a disease of the elderly. About half of people who have HF die within 5 years of diagnosis, and 90% of patients who have HF die within 10 years. See “Heart Failure, Chronic.”

ETIOLOGY AND PATHOPHYSIOLOGY

  • Two main pathophysiologic conditions lead to the clinical findings of HF, namely systolic and/or diastolic dysfunction. See “Heart Failure, Chronic.” Systolic dysfunction is an inotropic abnormality, while diastolic dysfunction is a compliance abnormality.
    • The terms HF with reduced, midrange, or preserved LVEF (HFrEF, HFmrEF, HFpEF, respectively) describe the HF phenotypes.
    • 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 vascular and/or systemic venous 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 can be triggered by medication noncompliance, diet, infection, or some other acute insult such as coronary artery disease (CAD) and myocardial infarction (MI), immune-mediated and inflammatory damage, infiltrative diseases, metabolic derangements, toxins, and genetic abnormalities.
    • Valvular disease: progressive or acute regurgitant or stenotic valvular lesions
    • Abnormal ventricular filling: elevated afterload and hypertension (HTN), valvular and myocardial structural defects, pericardial and endomyocardial pathologies, high-output states, volume overload
    • Arrhythmias: atrial fibrillation, tachyarrhythmias, high-grade heart block, bradyarrhythmias
  • Approximately 70% of patients with ADHF have worsening chronic HF, 25% present with HF for the first time, and 5% present with advanced or end-stage HF.

Genetics

See “Heart Failure, Chronic.”

RISK FACTORS

See “Heart Failure, Chronic.”

GENERAL PREVENTION

See “Heart Failure, Chronic.”

COMMONLY ASSOCIATED CONDITIONS

Patients with HF commonly have comorbid conditions. These commonly include CAD, HTN, obesity, diabetes mellitus, and chronic kidney disease.

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