Heart Failure, Acutely Decompensated



Acute decompensated heart failure (ADHF) is a heterogenous group of syndromes characterized by new onset or recurrence of structural or functional cardiac pump impairment severe enough for patients to seek medical attention. Symptoms of ADHF are most often 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 heart failure (HF). A number of terms have been used to describe this pathology including acute HF and acute decompensation of chronic HF.


Incidence, prevalence, and costs of HF are discussed in the chapter on “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.

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 (also called mildly reduced), 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 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, 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.
    • 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

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.

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