Salud

Crit Care Clin 23 (2007) 737–758

Acute Decompensated Heart Failure
James F. Neuenschwander II, MD, FACEPa, Ragavendra R. Baliga, MD, MBA, FRCP, FACCb,c,*
Emergency Department, The Ohio State University Medical Center, 1492 E. Broad Street, #1104, Columbus, OH 43205, USA b Cardiovascular Medicine, University Hospitals East, The Ohio State University, 1492 E. Broad Street, #1104, Columbus, OH43205, USA c The Ohio State University, 1492 E. Broad Street, #1104, Columbus, OH 43205, USA
a

Acute decompensated heart failure (ADHF) is the direct cause of approximately one million hospital admissions and contributes to an additional 2.4 million hospitalizations in the United States. It accounts for over 50% of the total annual direct costs for heart failure (HF) [1,2]. The in-hospitalmortality is in the range of 3% to 4%, and more significantly, the 60- to 90-day mortality rates approach 10% [3]. The burden becomes even more significant when one considers that almost 50% of all patients admitted with this diagnosis are readmitted within 90 days after they are discharged. Although as many as 60% of all patients hospitalized for HF die within 1 year, only about 5% to 8% actually diein the hospital [3]. This clearly places the responsibility of HF management in the hands of emergency department (ED) physicians, internists, cardiologists, family practice physicians, and nurses, who rapidly must diagnose and treat the symptoms of HF both acutely and in the long-term outpatient setting. Definition ADHF refers broadly to new or worsening of signs and symptoms of HF that isprogressing rapidly, whereby unscheduled medical care or hospital evaluation is necessary. The mode of presentation of acute HF depends on the etiology and accompanying comorbidities. Common etiologies of ADHF include ischemic cardiomyopathy (60%), hypertension (70%), nonischemic cardiomyopathy, valvular disease, pericardial disease, and acute
* Corresponding author. The Ohio State University, 1492 E.Broad Street, #1104, OH 43205. E-mail address: ragavendra.baliga@osumc.edu (R.R. Baliga). 0749-0704/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.ccc.2007.08.003 criticalcare.theclinics.com

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myocarditis (Box 1). Typically ADHF is a consequence of impaired left ventricular (LV) function, either systolic or diastolic, withdiastolic dysfunction and hypertension contributing to as much as 50% of all HF-related hospitalizations. Also, about 50% of the patients who have ADHF have reactive hypertension that tends to return to normal within 6 hours of appropriate treatment. Common clinical presentations include ADHF, acute HF accompanying elevation of systemic blood pressure, pulmonary edema, cardiogenic shock with or withoutlow-output syndrome, high-output cardiac failure, and right-sided failure (Table 1) [4]. The management of ADHF is urgent to reduce mortality, decrease length of stay, and avoid need for therapies such as mechanical ventilatory support. The management of ADHF is complicated, however, because many disease processes present with similar symptoms. For example, shortness of breath can be the chiefcomplaint of many other illnesses such as, pneumonia, pulmonary embolism, myocardial infarction, chronic obstructive pulmonary disease (COPD) exacerbation, and asthma. Specifically, differential diagnoses include:         Myocardial infarction Congestive HF Pneumonia COPD exacerbation Cardiac tamponade Anxiety Pulmonary embolism Asthma

Box 1. Common precipitating factors in decompensatedheart failure Medicine and dietary noncompliance Cardiac causes Ischemia Arrhythmia Uncontrolled hypertension Noncardiac causes Infection (pneumonia with or without hypoxia) Exacerbation of comorbidity (chronic obstructive pulmonary disease) Pulmonary embolus Toxins (nonsteroidal anti-inflammatory drugs) Volume overload

Table 1 Modes of presentation of ADHF [4] Systolic blood pressure mm Hg Low...