Heart Failure, Acutely Decompensated



Acute decompensated heart failure (ADHF) is a heterogenous group of related syndromes with new-onset or recurrence of cardiac pump function impairment severe enough for patients to seek medical attention. ADHF may be due to complications arising from the pericardium, myocardium, endocardium, or the heart valves. This leads to a wide variety of symptoms secondary to impairment of ventricular filling or ejection of blood resulting in pulmonary congestion, systemic congestion, as well as tissue hypoperfusion. 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.



  • Incidence, prevalence, and costs of HF are discussed in the chapter on “Heart Failure, Chronic.”
  • 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.

HF is primarily a disease of the elderly; 75% of hospital admissions for HF are in persons >65 years of age. 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

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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