6. Acute Heart Failure (ADHF)

Quick Recap

Cardiovascular System, Protocol 7/12. Acute Decompensated Heart Failure (ADHF).

1. Definition

ADHF = new-onset or worsening signs/symptoms of heart failure requiring urgent evaluation/therapy, typically pulmonary and/or systemic congestion +/- low cardiac output. ~6.7 million Americans living with HF, ~1 million new cases/year; 1-year mortality approaches 50% for advanced HF; leading cause of hospitalization in patients >=65.

Only 5-8% of ADHF patients present with SBP <90 mmHg — most present with preserved/elevated BP. Hypotensive ADHF with creatinine >2 mg/dL carries inpatient mortality >16% and should prompt ICU admission consideration, as should any evidence of hypoperfusion.

2. Forrester / Clinical Profile Classification

Uses either noninvasive (clinical congestion + perfusion assessment) or invasive hemodynamic data (CI, PCWP) to categorize and directly guide therapy:

A PA catheter (Swan-Ganz) can be used when clinical hemodynamic/volume assessment is unclear or in shock, providing CI/PCWP/SVR and allowing response-to-therapy monitoring — but carries procedural risk and should be reserved for selected cases, placed by an experienced operator.

3. Immediate Stabilization (ABCDE)

Airway/Breathing: avoid routine supplemental O2 in non-hypoxic patients — hyperoxia causes vasoconstriction and can reduce cardiac output; NIV for pulmonary edema with respiratory distress; intubate for respiratory failure.

Circulation — by Forrester profile (Section 2):

Profile II (wet + warm) — diuresis + vasodilation, the most common ADHF ICU presentation:

• IV loop diuretics at 2-2.5x usual oral daily dose — effects on right atrial pressure/PCWP/PVR within 5-30 minutes
• Mild-moderate: furosemide 20-80mg PO/IV
• Severe: furosemide 40-120mg IV or drip 2-20 mg/h (bolus up to q6h)
• Alternative: bumetanide 1-4mg IV or drip 1-2 mg/h
• Refractory to loop alone: add metolazone 2.5-5mg PO or chlorothiazide 250-500mg IV 30 min before each furosemide dose — most effective when CrCl <30
• Refractory to loop + thiazide combination: consider inotrope (dobutamine) if renal perfusion inadequate, or renal replacement therapy (HD/CVVHDF) for volume control
• Renal dysfunction is NOT a reason to withhold diuresis — renal function often improves WITH decongestion
• Vasodilators (first-line for ADHF with MI/pulmonary edema specifically, all carry hypotension risk):
• IV nitroglycerin 10-200 mcg/min — balanced arterial/venous vasodilator at HIGHER doses; at LOW doses it's primarily venodilatory and may not adequately unload the heart — titrate aggressively with close BP monitoring, especially with concurrent ischemia; combination with IV loop diuretics is more effective than high-dose diuretics alone
• IV nitroprusside 0.5-5 mcg/min — balanced arterial/venous vasodilation AT ALL DOSES (unlike nitroglycerin), short half-life, may be better tolerated at lower presenting BPs; watch for isocyanate/cyanide toxicity with prolonged/high-dose use
• IV nicardipine 0.5-2.5 mcg/kg/min — predominantly ARTERIAL vasodilator (dihydropyridine CCB, safe in ADHF unlike non-DHP CCBs), minimal preload effect — less ideal if volume overload is the dominant problem, reflex tachycardia risk

Profile IV (wet/dry + cold) — inotropes/vasopressors:

Contraindicated/cautioned medications in ADHF:

• Non-dihydropyridine CCBs (diltiazem, verapamil): CONTRAINDICATED — negative inotropic effect
• IV beta-blockers/CCBs for rate control: generally avoided given myocardial depressive effects; digoxin preferred for rate control in ADHF, especially with hypotension
• Chronic beta-blocker therapy: may need dose reduction but should NOT be abruptly discontinued (absent hypoperfusion) — risk of rebound catecholamine surge
• Morphine: can relieve dyspnea/reduce PVR but risks exacerbating hypotension — use cautiously, not routine

Sedation choices if intubated: midazolam is more hemodynamically neutral than propofol in ADHF, though carries its own delirium/prolonged-ventilation tradeoffs — individualize.

Disability/Exposure: DVT prophylaxis in all ADHF patients not already therapeutically anticoagulated (HF is a hypercoagulable state).

Checklist:

4. Focused History

HF etiology (ischemic vs non-ischemic), medication adherence, dietary indiscretion (sodium/fluid), known EF (HFrEF vs HFpEF changes some management nuance), recent MI/arrhythmia trigger, renal function trend, home diuretic dose (to calculate IV equivalent), anticoagulation status, prior LVAD/transplant candidacy discussions.

5. Examination + POCUS

JVP, S3, rales, peripheral edema, hepatomegaly/ascites (right-sided congestion), cool extremities/narrow pulse pressure (low output).

POCUS: lung B-lines (congestion), IVC plethora/collapsibility, LV function/EF estimate, RV function, valvular assessment — central to Forrester profile assignment when clinical exam is ambiguous.

6. Syndrome Identification

Confirm cardiogenic pulmonary edema/congestion (vs ARDS, vs pneumonia) via POCUS/BNP; determine Forrester profile to select therapy pathway.

7. Differential Diagnosis

8. Severity Assessment

Forrester classification (Section 2) is the primary framework. General ICU severity (SOFA/APACHE II) for overall prognostication. BNP/NT-proBNP trend supports diagnosis and response to therapy (though absolute levels vary with renal function/obesity/chronicity).

9. Investigations

• Bedside: ECG (arrhythmia, ischemia), POCUS (Section 5), SpO2
• Labs: BNP/NT-proBNP, troponin (exclude concurrent ACS), renal function/electrolytes (diuretic monitoring), TSH, CBC (anemia as precipitant)
• Imaging: CXR, echo (EF, valvular disease, RV function)
• Invasive hemodynamics: PA catheter if clinical assessment inadequate or in shock (Section 2)

10. Chronic HF Medication Management During ADHF

• ACEI/ARB: role in acute setting less clear; may need dose reduction/hold to facilitate diuresis without worsening renal function; cautious ICU initiation possible with careful monitoring (e.g., captopril 6.25-12.5mg q6-8h titrated to SBP<100/reduced SVR/max 300mg/day); for de-novo initiation in HF patients, wait ~48h after ADHF stabilization (Class I, Level A), typically post-ICU transfer
• Fluid restriction (<2L/day) recommended for moderate hyponatremia and advisable for all fluid-overloaded patients; vasopressin receptor antagonists ("vaptans") can be considered carefully for severe hyponatremia — relax fluid restriction during vaptan use
• Beta-blockers/CCBs: limited acute role; see cautions in Section 3

11. Mechanical Circulatory Support

For patients not stabilizing with medical therapy, especially if candidates for advanced HF therapy (transplant, durable LVAD):

• IABP: afterload reduction + augmented diastolic coronary filling in low-output states
• TandemHeart: left atrium-to-femoral-artery bypass (transseptal inflow cannula), up to 4 L/min
• Impella: percutaneous microaxial LVAD across the aortic valve, 2.5-5.5 L/min depending on model
• ECMO: circulatory + respiratory support as a bridge to LVAD/transplant in severely decompensated HF
• CVVHDF: for volume control in diuretic-refractory patients with renal failure
• Early involvement of advanced HF cardiology and cardiac surgery is important to determine candidacy for durable device/transplant pathways before pursuing temporary MCS in a vacuum

(See Cardiogenic Shock protocol for the full MCS device comparison table and SCAI staging framework, which applies when ADHF progresses to cardiogenic shock.)

12. Organ Support

Diuresis/vasodilation/inotropes per Forrester profile; MCS per Section 11 for refractory cases; RRT for diuretic-refractory volume overload with renal failure; DVT prophylaxis; standard ICU supportive care.

13. Consultation Matrix

14. Monitoring Framework

Daily weights, strict I/O, serial renal function/electrolytes during diuresis, serial BNP trend, continuous telemetry (arrhythmia risk), reassess Forrester profile as therapy progresses.

15. ICU Bundle Checklist (Daily)

16. Complications

Worsening renal function (cardiorenal syndrome — does not always mean stop diuresis, see Section 3), electrolyte derangement (hypokalemia, hyponatremia) from diuresis, arrhythmia, hypotension from vasodilator/diuretic therapy, thromboembolism (hypercoagulable state). Prevention: careful diuretic titration with renal/electrolyte monitoring, DVT prophylaxis, cautious vasodilator titration. Rescue: RRT for refractory volume overload, MCS for refractory low-output state.

17. Escalation & De-escalation

Escalate: Profile III/IV not responding to initial therapy, worsening perfusion -> inotropes, consider MCS, engage advanced HF team.

De-escalate: euvolemic, warm, stable on oral diuretics -> transition IV to oral diuretic (typically 2x IV dose as new oral dose), resume/initiate GDMT per Section 10 timing, plan cardiac rehab/outpatient HF follow-up.

18. ICU Discharge Criteria

Euvolemic or near-goal weight, stable renal function/electrolytes, transitioned to oral diuretic regimen, GDMT resumption plan in place, no ongoing arrhythmia/ischemia, advanced HF follow-up arranged if applicable.

19. Documentation & Medicolegal Checklist

20. Key Guidelines

ISHLT/HFSA Guideline on Acute Mechanical Circulatory Support (Bernhardt et al., 2023); ACC/AHA/HFSA Heart Failure Guidelines (chronic HF management framework referenced for post-stabilization GDMT).

21. Controversies

Evidence base for ADHF-specific management is notably weaker than for chronic HF — most acute therapies (diuretic strategy, vasodilator choice, inotrope selection) are guided by physiologic reasoning and observational data rather than large RCTs, unlike the well-established chronic HF GDMT evidence base. Optimal diuretic strategy (continuous infusion vs bolus dosing) has been studied (e.g., DOSE trial) without a clear universal winner. Timing of MCS escalation (early/proactive vs reserved for refractory cases) parallels the same debate seen in the Cardiogenic Shock protocol.

22. References

1. Giacomino BD, Ewald GA. Acute Decompensated Heart Failure. Washington Manual of Critical Care, 4th ed, 2025 (Ch. 23).
2. Bernhardt AM, Copeland H, Deswal A, et al. ISHLT/HFSA guideline on acute mechanical circulatory support. J Heart Lung Transplant. 2023;42(4):e1-e64.
3. Forrester JS, Diamond G, Chatterjee K, Swan HJ. Medical therapy of acute myocardial infarction by application of hemodynamic subsets. N Engl J Med. 1976;295(24):1356-1362 (original Forrester classification).
4. Crespo-Leiro MG, Metra M, Lund LH, et al. Advanced heart failure: a position statement (referenced in Washington Manual Ch. 23 suggested readings).