Acute heart failure
Acute heart failure is the rapid onset or worsening of heart failure symptoms requiring urgent therapy, most often pulmonary congestion from a precipitant such as ischemia, arrhythmia, or nonadherence. Management is oxygen, intravenous diuretics, and vasodilators for the congested-but-perfused patient, with inotropes or support for the hypoperfused patient.
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What this article covers
- Overview
Definition: acute heart failure is the rapid onset or worsening of heart failure signs and symptoms requiring urgent evaluation and treatment, whether new-onset or a decompensation of chronic disease.
- Epidemiology
A leading cause of hospital admission in older adults.
- Risk factors
Established heart failure and its causes (ischemia, hypertension, valve disease).
- Pathophysiology
Elevated filling pressures: an acute rise in left ventricular filling pressure causes pulmonary congestion and edema.
- Clinical features
Acute dyspnea, orthopnea, and pulmonary crackles.
- Differential diagnosis
Chronic obstructive pulmonary disease exacerbation: wheeze and airflow limitation with prolonged expiration, distinguished by a normal natriuretic peptide and hyperinflation rather than vascular congestion on chest imaging.
- Diagnosis
Establish clinically with natriuretic peptides and imaging, and classify by congestion and perfusion: the diagnostic basis is the acute congestion syndrome supported by an elevated BNP or NT-proBNP…
- Management
First-line, treat the warm-and-wet patient with oxygen, diuresis, and vasodilation: give supplemental oxygen (and noninvasive positive-pressure ventilation for severe distress), an intravenous loop…
- Complications
Respiratory failure and the need for ventilation.
- Prognosis
Substantial in-hospital and post-discharge mortality.
- Prevention
Optimize and adhere to guideline-directed heart failure therapy.
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Related articles
- Heart failure
Heart failure is a clinical syndrome of impaired cardiac filling or ejection causing congestion and reduced perfusion, classified by ejection fraction. Diagnosis integrates symptoms, signs, natriuretic peptides, and echocardiography, and treatment of reduced-ejection-fraction disease is quadruple guideline-directed therapy, with device therapy and cause-specific management.
- Cardiogenic shock
Cardiogenic shock is primary cardiac pump failure that produces sustained hypotension and end-organ hypoperfusion despite adequate filling, most often from a large acute myocardial infarction. Survival depends on emergently reversing the cause, usually by revascularization, while supporting perfusion with vasopressors, inotropes, and, when refractory, mechanical circulatory support.
- Cardiorenal syndrome
Cardiorenal syndrome is the bidirectional dysfunction in which heart disease impairs the kidneys or kidney disease impairs the heart, classified into five types. In decompensated heart failure it is driven more by venous congestion than low output, so the core treatment is decongestion with adequate diuresis while preserving perfusion.
- Cardiac tamponade
Cardiac tamponade is life-threatening compression of the heart by a pericardial effusion, impairing diastolic filling and cardiac output. It presents with hypotension, distended neck veins, and pulsus paradoxus, is confirmed by echocardiography, and is treated by urgent pericardiocentesis; avoid vasodilators and aggressive diuresis.
- Mitral regurgitation
Mitral regurgitation is systolic backflow from the left ventricle into the left atrium, classified as primary (valve disease) or secondary (ventricular or annular disease). Chronic disease causes volume overload with an apical holosystolic murmur, while acute severe regurgitation causes pulmonary edema; severe primary disease is treated with valve repair or replacement.
- Secondary hypertension
Secondary hypertension is high blood pressure from an identifiable, often correctable cause, such as primary aldosteronism, renal or renovascular disease, obstructive sleep apnea, or endocrine tumors. It should be suspected with resistant, early-onset, or abrupt hypertension, and identifying the cause can cure or greatly improve control.