Acute decompensated heart failureMANAGEMENT

CARDIOVASCULAR PRESENTATIONS · 12 SECTIONS

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757 items

☷ Legend

01Approach to the Critical Patient/attcp98

First look and triggers

›High risk states

›Respiratory failure

›SpO2 < 90% on room air

›Rising PaCO2 with fatigue

›Shock

›SBP < 90 mmHg

›MAP < 65 mmHg

›Lactate >= 2.0 mmol/l

›Ischemia

›Ongoing chest pain

›New ischemic ECG changes

›Malignant arrhythmia

›Sustained VT

›AF with RVR and instability

›Altered mental status

›Suspected hypercapnia

›Hypoperfusion

Resuscitation priorities

›Airway and breathing

›Positioning

›Upright

›Legs dependent if severe congestion

›Oxygen strategy

›SpO2 target 92% to 96%

›COPD or chronic hypercapnia target 88% to 92%

›Noninvasive ventilation

›CPAP 5 to 10 cmH2O

›BiPAP IPAP 10 to 15 cmH2O

›BiPAP EPAP 5 to 8 cmH2O

›If worsening mental status, prepare intubation

›Intubation risk reduction

›Preoxygenation with NIV

›Avoid large induction doses in shock

›Post intubation hypotension plan

›Circulation and perfusion

›Monitoring

›Continuous ECG

›Noninvasive BP q 3 to 5 min

›Arterial line if vasoactive infusions

›Foley for hourly urine output if severe

›IV access

›Two large bore IV

›Central access if vasopressors expected

›Fluid strategy

›Avoid empiric fluid bolus in pulmonary edema

›If suspected RV infarct and underfilled, small bolus 250 ml with reassessment

›Immediate reversible causes

›ACS

›If STEMI, activate cath lab

›If NSTEMI with shock, urgent cardiology

›Hypertensive emergency

›Rapid symptom relief with vasodilator if no contraindication

›Arrhythmia driven decompensation

›If unstable, synchronized cardioversion

›If stable, rate control based on LV function

›Mechanical complication

›Acute severe MR

›VSD

›Tamponade

›PE

›If shock and high suspicion, PE pathway

›Infection

›Sepsis triggers with lactate and cultures

Hemodynamic phenotypes

›Profile classification

›Warm and wet

›Congestion with preserved perfusion

›Primary strategy IV diuresis

›Cold and wet

›Congestion with hypoperfusion

›Primary strategy inotrope plus diuresis

›Warm and dry

›Alternative diagnosis likely

›Discharge pathway if safe

›Cold and dry

›Underfilled or advanced pump failure

›Small fluid challenge only if underfilled evidence

Early bedside targets

›Symptom targets

›Dyspnea improvement within 30 to 60 min

›Work of breathing reduction with NIV

›Decongestion targets

›Urine output >= 100 to 150 ml per hour early response

›Net negative 1 to 2 l per 24 hours if tolerated

›Safety targets

›MAP >= 65 mmHg

›Creatinine trend stable or expected mild rise

›Potassium 3.5 to 5.0 mmol/l

Consultation and pathways

›Early specialist triggers

›Cardiogenic shock or inotrope requirement

›ICU admission

›Advanced HF or critical care consult

›Refractory hypoxemia on NIV

›ICU admission

›Airway team

›Suspected ACS

›Cardiology consult

›Cath lab activation criteria

›Suspected mechanical cause

›Emergent echocardiography

›Cardiothoracic surgery notification if indicated

02History/hx84

Presenting syndrome

›Dyspnea pattern

›Orthopnea

›Paroxysmal nocturnal dyspnea

›Dyspnea at rest

›Volume symptoms

›Rapid weight gain

›Peripheral edema

›Abdominal distension

›Perfusion symptoms

›Syncope or presyncope

›Cold extremities

›Oliguria

›Chest symptoms

›Chest pain

›Palpitations

›Time course

›Hours onset suggests flash pulmonary edema

›Days onset suggests progressive congestion

›Weeks onset suggests chronic deterioration

Triggers and precipitants

›Ischemic trigger

›Exertional angina

›Recent MI

›Arrhythmia trigger

›AF onset

›ICD shocks

›Hypertension trigger

›Medication nonadherence

›Recent NSAID use

›Infection trigger

›Fever

›Productive cough

›PE trigger

›Pleuritic pain

›VTE risk factors

›Renal trigger

›Reduced urine output

›Recent dehydration or diuretic change

›Medication trigger

›NSAIDs

›Non DHP CCB in HFrEF

›Thiazolidinediones

›Negative inotropes

›Substance trigger

›Cocaine or stimulant use

›Alcohol binge

HF phenotype and baseline

›Known LVEF category

›HFrEF LVEF <= 40%

›HFmrEF LVEF 41% to 49%

›HFpEF LVEF >= 50%

›Baseline functional class

›NYHA class

›Baseline exercise tolerance

›Prior decompensations

›Prior admissions in last 6 months

›Prior ICU

›Prior intubation

›Baseline meds and adherence

›Loop diuretic dose

›ARNI or ACEi or ARB

›Beta blocker

›MRA

›SGLT2 inhibitor

›Devices

›ICD

›CRT

›LVAD

Comorbidities and risk

›CAD

›Prior PCI or CABG

›Angina history

›Valvular disease

›AS

›MR

›CKD

›Baseline creatinine

›Dialysis status

›COPD or asthma

›Home oxygen

›Hypercapnia history

›Diabetes

›Hypoglycemia risk

›Ketoacidosis risk factors

›Anemia or bleeding

›GI bleed symptoms

›Anticoagulant use

03Physical Exam/exam57

Vitals and appearance

›Respiratory status

›RR

›Accessory muscle use

›Inability to speak full sentences

›Oxygenation

›SpO2 on room air

›SpO2 on supplemental oxygen

›Hemodynamics

›SBP

›MAP

›Pulse pressure

›Temperature

›Perfusion

›Cool extremities

›Delayed capillary refill

›Mottling

›Mental status

›Agitation from hypoxemia

›Somnolence from hypercapnia

Volume and congestion

›Neck

›JVP elevation

›Hepatojugular reflux

›Lungs

›Crackles

›Wheeze

›Diminished bases

›Heart

›S3

›New murmur

›Abdomen

›Hepatomegaly

›Ascites

›Extremities

›Pitting edema

›Asymmetric edema

Etiology clues

›Ischemia signs

›Diaphoresis

›New S4

›Infection signs

›Fever

›Focal lung findings

›PE signs

›Unilateral leg swelling

›Pleuritic features

›Tamponade signs

›Elevated JVP with clear lungs

›Pulsus paradoxus

›RV failure signs

›Marked JVP

›Hepatic congestion

›Minimal rales

PITFALLS

›Exam limitations

›Crackles absent in chronic congestion

›Obesity limits JVP accuracy

›Misleading findings

›Wheeze from pulmonary edema

›Normal BP in shock with vasoconstriction

04Differential Diagnosis/ddx39

Life threats to exclude

›ACS

›STEMI ICD-10 I21

›NSTEMI ICD-10 I21.4

›Pulmonary embolism

›Acute PE ICD-10 I26

›Aortic dissection

›Dissection ICD-10 I71.0

›Cardiac tamponade

›Tamponade ICD-10 I31.4

›Malignant arrhythmia

›VT ICD-10 I47.2

›Hypertensive emergency

›Hypertensive crisis ICD-10 I16

Mimics and contributors

›COPD exacerbation

›ICD-10 J44.1

›Pneumonia

›ICD-10 J18.9

›Asthma exacerbation

›ICD-10 J45.901

›ARDS

›ICD-10 J80

›Renal failure with volume overload

›AKI ICD-10 N17.9

›Cirrhosis with ascites

›ICD-10 K74.60

›Anemia

›ICD-10 D64.9

›Thyrotoxicosis

›ICD-10 E05.90

HF specific entities

›Acute decompensated heart failure

›ICD-10 I50.21 acute systolic HF

›ICD-10 I50.23 acute on chronic systolic HF

›ICD-10 I50.31 acute diastolic HF

›ICD-10 I50.33 acute on chronic diastolic HF

›Cardiogenic shock

›ICD-10 R57.0

›Flash pulmonary edema

›Associated with severe hypertension

›Associated with acute MR

05Laboratory Tests/lt60

Core labs

›Baseline safety set

›Electrolytes

›Sodium

›Potassium

›Chloride

›Bicarbonate

›Renal function

›Urea

›Creatinine

›Glucose

›Hypoglycemia exclusion

›Hyperglycemia management planning

›Complete blood count

›Anemia contributor

›Leukocytosis infection clue

›Liver enzymes

›Congestive hepatopathy clue

›Ischemic hepatitis clue in shock

Cardiac biomarkers and HF markers

›Natriuretic peptides

›BNP interpretation

›Higher values increase likelihood of HF

›Lower values make HF less likely

›NT-proBNP interpretation

›Renal dysfunction increases baseline

›Obesity lowers baseline

›Diagnostic limitations

›Atrial fibrillation elevates baseline

›Advanced age elevates baseline

›Troponin

›ACS evaluation

›Dynamic rise or fall supports acute injury

›ECG correlation required

›HF injury pattern

›Mild elevation common in ADHF

›Prognostic association with mortality

Respiratory and perfusion labs

›Blood gas selection

›VBG for hypercapnia screening

›pCO2 trend

›ABG for severe hypoxemia or ventilation failure

›PaO2 mmHg

›PaCO2 mmHg

›Lactate

›Hypoperfusion marker

›>= 2.0 mmol/l suggests impaired perfusion

›Procalcitonin

›Pneumonia differentiation support

›Antibiotic stewardship adjunct

Additional directed labs

›Thyroid function

›New AF or unexplained decompensation

›Iron studies

›Chronic HF optimization planning

›D-dimer

›PE evaluation in low risk phenotype

›Limited specificity in HF

PITFALLS

›Creatinine rise during decongestion

›Mild rise may be acceptable with clinical improvement

›Severe rise with hypotension suggests overdiuresis or shock

›Hyponatremia

›Marker of severe HF and neurohormonal activation

›Rapid correction risk with hypertonic therapy

06Diagnostic Tests/dt85

Scoring Systems

›Risk stratification tools

›ADHERE risk tree

›BUN elevation high risk marker

›SBP low risk marker when high

›Creatinine elevation high risk marker

›EHMRG

›ED mortality prediction

›Uses age, vitals, creatinine, potassium, troponin, cancer history

›GWTG-HF risk score

›Inpatient mortality risk estimation

›Uses SBP, BUN, sodium, HR, COPD, race

›Limitations

›Do not replace clinical judgement

›External validation variability

MRI

›Cardiac MRI role

›Myocarditis evaluation

›Tissue characterization

›Edema assessment

›Infiltrative cardiomyopathy

›Amyloidosis patterns

›Sarcoidosis patterns

›Viability assessment

›Ischemic cardiomyopathy planning

›Acute ED limitations

›Not first line for unstable ADHF

›Device compatibility constraints

›Chest CT indications

›Alternative diagnosis search

›Pneumonia

›PE if CTA

›Aortic pathology

›CTA aorta for dissection concern

›Pulmonary edema characterization

›Interstitial edema patterns

›Contrast risk

›CKD risk balancing with diagnostic yield

Ultrasound

›Point of care ultrasound

›Lung ultrasound

›Diffuse B lines supports pulmonary edema

›Pleural effusions

›Focal consolidation suggests pneumonia

›Cardiac ultrasound

›LV systolic function gross estimate

›RV dilation for PE or RV failure

›Pericardial effusion for tamponade

›IVC assessment

›Plethoric IVC supports elevated RA pressure

›Collapsible IVC suggests low filling pressures

›Venous ultrasound

›DVT evaluation if PE concern

ECG and radiography

›ECG

›Ischemia patterns

›ST elevation

›ST depression

›New T inversion

›Arrhythmias

›AF

›Flutter

›VT

›Conduction disease

›LBBB

›High grade AV block

›Chest radiograph

›Pulmonary edema signs

›Interstitial edema

›Kerley lines

›Alveolar edema

›Pleural effusions

›Bilateral typical

›Cardiomegaly

›Chronic HF marker

›Alternative diagnoses

›Pneumonia

›Pneumothorax

Formal echocardiography

›Echo indications

›New HF diagnosis

›Suspected mechanical cause

›Shock or hypotension

›Unclear volume status

›Echo deliverables

›LVEF

›RV function

›Valvular disease

›Pericardial effusion

›Filling pressures estimate

07Disposition/dispo30

Level of care selection

›ICU criteria

›NIV dependence with fatigue

›Intubation

›Cardiogenic shock

›Vasopressor or inotrope infusion

›Refractory arrhythmia

›Stepdown criteria

›Ongoing IV diuresis with monitoring needs

›Stable on low flow oxygen

›Recent hypertensive pulmonary edema after stabilization

›Ward criteria

›Hemodynamically stable

›Responding to diuresis

›No active ischemia

ED observation and discharge pathway

›Observation candidates

›Mild congestion

›Rapid response to IV diuretic

›No hypoxemia after treatment

›Reliable follow up within 72 hours

›Discharge criteria

›SpO2 stable on room air or baseline

›Ambulation without dyspnea at rest

›No ischemic symptoms

›Stable renal function and electrolytes

›Oral diuretic plan established

›Education and return precautions completed

Transfer criteria

›Advanced therapies need

›Mechanical circulatory support evaluation

›Urgent revascularization capability

›Severe valvular emergency intervention

08Treatment/t173

Nonpharmacologic and respiratory support

›Supportive measures

›Positioning

›Upright

›Legs dependent for severe dyspnea

›Fluid and sodium strategy

›Fluid restriction 1.5 to 2.0 l per day for hyponatremia or severe congestion

›Sodium restriction 2 g per day typical inpatient target

›Thromboprophylaxis

›Pharmacologic VTE prophylaxis unless contraindicated

›Noninvasive ventilation

›CPAP

›Start 5 cmH2O

›Titrate to 10 cmH2O for work of breathing

›BiPAP

›IPAP 10 cmH2O

›EPAP 5 cmH2O

›Titrate IPAP by 2 to 3 cmH2O for ventilation

›Titrate EPAP by 1 to 2 cmH2O for oxygenation

›Contraindications

›Vomiting or high aspiration risk

›Inability to protect airway

›Facial trauma

Diuretics and decongestion

›Loop diuretics

›Furosemide IV

›Diuretic naive 20 to 40 mg IV

›Reassess urine output at 60 to 120 min

›If inadequate, double dose

›Chronic loop therapy initial IV dose

›1 to 2 times total daily oral dose as IV

›If on 80 mg oral daily, consider 40 to 80 mg IV

›Continuous infusion option

›Bolus 40 mg IV

›Infusion 5 to 10 mg per hour

›Titrate 2.5 to 5 mg per hour q 2 to 4 hours

›Bumetanide IV

›0.5 to 1.0 mg IV initial

›Approximate equivalence furosemide 40 mg

›Infusion 0.5 to 2 mg per hour

›Titrate by 0.5 mg per hour

›Torsemide IV or PO

›10 to 20 mg IV or PO initial

›Higher bioavailability supports oral transition

›Monitoring

›Potassium q 6 to 12 hours if aggressive diuresis

›Magnesium daily or more frequent if arrhythmia risk

›Creatinine daily or more frequent if shock risk

›Diuretic resistance strategy

›If urine output < 100 ml per hour after adequate loop dose, add thiazide type

›Metolazone PO 2.5 to 5 mg

›Dose 30 to 60 min before loop

›High hypokalemia risk monitoring

›Chlorothiazide IV 500 mg

›Repeat 500 mg q 12 to 24 hours

›Monitor sodium for hyponatremia

›If persistent congestion, consider acetazolamide

›Acetazolamide IV 500 mg daily

›Add on to loop diuretic

›Monitor bicarbonate for metabolic acidosis

›Ultrafiltration

›Indications

›Refractory congestion despite pharmacologic therapy

›Severe renal dysfunction limiting diuretics

›Risks

›Hypotension

›Catheter complications

Vasodilators for hypertensive or warm wet ADHF

›Nitrates

›Nitroglycerin IV infusion

›Start 10 to 20 mcg per min

›Titrate by 10 to 20 mcg per min q 3 to 5 min

›Typical range 50 to 200 mcg per min

›Higher doses 200 to 400 mcg per min for severe hypertension with monitoring

›Contraindications

›SBP < 90 mmHg

›Suspected RV infarct

›PDE5 inhibitor recent use

›Nitroglycerin SL

›0.4 mg q 5 min

›Max 3 doses while IV prepared

›Nitroprusside IV infusion

›Start 0.3 mcg per kg per min

›Titrate by 0.2 to 0.5 mcg per kg per min q 5 min

›Typical max 5 mcg per kg per min

›Arterial line preferred

›Contraindications or cautions

›Severe renal failure

›Severe hepatic failure

›Risk of cyanide or thiocyanate toxicity with prolonged use

›Nicardipine IV infusion

›Start 5 mg per hour

›Titrate 2.5 mg per hour q 5 to 15 min

›Max 15 mg per hour

›Use case

›Hypertensive pulmonary edema when nitrate limited

Inotropes and vasopressors for cold profile or shock

›Inotropes

›Dobutamine IV infusion

›Start 2.5 mcg per kg per min

›Titrate 2.5 mcg per kg per min q 10 to 30 min

›Typical range 2.5 to 20 mcg per kg per min

›Cautions

›Tachyarrhythmia risk

›Hypotension from vasodilation

›Milrinone IV infusion

›Loading dose avoided in hypotension

›Start 0.125 mcg per kg per min

›Titrate to 0.25 to 0.5 mcg per kg per min

›Renal dose adjustment required

›Cautions

›Hypotension risk

›Ventricular arrhythmia risk

›Vasopressors

›Norepinephrine IV infusion

›Start 0.02 mcg per kg per min

›Titrate q 2 to 5 min to MAP target

›Typical range 0.02 to 0.3 mcg per kg per min

›Rationale

›First line for cardiogenic shock with hypotension

›Vasopressin IV infusion

›0.03 units per min

›Adjunct to norepinephrine

›Avoid higher doses due to ischemia risk

›Hemodynamic targets in shock

›MAP >= 65 mmHg

›Lactate downtrend

›Urine output >= 0.5 ml per kg per hour

Rate and rhythm management

›Unstable tachyarrhythmia

›Synchronized cardioversion

›Sedation plan if time allows

›Post conversion anticoagulation plan

›AF with RVR and HFrEF

›Amiodarone IV

›150 mg over 10 min

›Repeat 150 mg if needed

›Infusion 1 mg per min for 6 hours

›Then 0.5 mg per min for 18 hours

›Digoxin IV

›0.25 mg IV

›Repeat 0.25 mg q 6 hours

›Max 1.0 mg in 24 hours

›Renal impairment dose reduction

›AF with RVR and HFpEF or preserved BP

›Diltiazem avoidance in HFrEF

›Metoprolol IV cautious use

›2.5 to 5 mg IV q 5 min

›Max 15 mg

›Avoid in shock or severe decompensation

Disease modifying meds in acute setting

›Beta blocker management

›If shock or inotrope need, hold

›If stable and chronic therapy, continue

›ACEi or ARB or ARNI management

›If AKI or hyperkalemia, hold

›If stable BP and renal function, continue

›MRA management

›If potassium > 5.0 mmol/l, hold

›If eGFR low, reassess risk

›SGLT2 inhibitor

›If hemodynamically stable, consider early initiation

›If ketoacidosis risk, hold

Analgesia and anxiolysis

›Opioids

›Avoid routine morphine

›Association with worse outcomes in observational studies

›Anxiolysis for NIV intolerance

›Low dose strategy

›Titrate to cooperation without hypoventilation

›Continuous monitoring

Evidence and guideline signals

›Guideline supported pillars in hospitalized HF

›IV loop diuretic for congestion

›Class I recommendation in major HF guidelines

›NIV for acute cardiogenic pulmonary edema

›Mortality and intubation reduction in meta analyses

›IV vasodilator for severe hypertension with pulmonary edema

›Symptom relief and afterload reduction

›Norepinephrine preferred vasopressor in cardiogenic shock

›Class IIa preference in shock guidance

09Special Populations/sp40

Pregnancy

›Pregnancy considerations

›Differential expansion

›Peripartum cardiomyopathy

›Preeclampsia related pulmonary edema

›Medication safety

›ACEi or ARB or ARNI contraindicated

›MRA contraindicated in pregnancy

›Nitrates acceptable for acute BP control

›Hydralazine acceptable for afterload reduction

›Imaging

›Echo preferred first line

›Minimize radiation and contrast when possible

›Consultation triggers

›Maternal fetal medicine

›Cardiology

Geriatric

›Geriatric considerations

›Presentation differences

›Confusion as primary symptom

›Less edema despite congestion

›Medication sensitivity

›Higher hypotension risk with vasodilators

›Higher electrolyte disturbance risk with diuretic stacking

›Goals of care

›Frailty assessment

›Advance directive review

Pediatrics

›Pediatric considerations

›Etiology differences

›Congenital heart disease

›Myocarditis

›Cardiomyopathy

›Red flags

›Poor feeding

›Hepatomegaly

›Tachypnea without wheeze

›Weight based dosing

›Furosemide 0.5 to 1 mg per kg IV

›Dobutamine 2 to 20 mcg per kg per min

›Early specialty involvement

›Pediatric cardiology

›PICU

10Background/b39

Epidemiology

›Epidemiology overview

›ADHF common cause of hospitalization in HF

›High early readmission risk within 30 days

›Mortality signals

›In hospital mortality higher with shock

›Post discharge mortality elevated in first months

›Phenotype distribution

›Majority present warm and wet

›Minority present cold and wet with highest risk

Pathophysiology

›Core mechanisms

›Elevated filling pressures

›Pulmonary congestion drives dyspnea

›Systemic venous congestion drives edema

›Neurohormonal activation

›RAAS activation increases sodium retention

›Sympathetic activation increases afterload

›Afterload mismatch

›Hypertensive crisis precipitates pulmonary edema

›Cardiorenal interaction

›Venous congestion reduces renal perfusion gradient

›Diuretic resistance from tubular adaptation

Therapeutic Considerations

›Treatment goals

›Rapid symptom relief

›NIV and vasodilators for pulmonary edema

›Effective decongestion

›Loop diuretics as first line

›Combination diuretics when resistant

›Preserve perfusion

›Avoid excessive preload reduction in RV failure

›Use vasopressor for hypotension before vasodilators

›Identify and treat precipitants

›ACS

›Arrhythmia

›Infection

›PE

›Harm avoidance

›Routine opioids associated with worse outcomes

›Excess IV fluids worsen pulmonary edema

›Inotropes increase arrhythmia risk and should be reserved for hypoperfusion

11Patient Discharge Instructions/pdi28

Copy discharge instructions

›Home plan

›Daily weights

›Same time each morning

›Same clothing

›Fluid plan

›Follow clinician target for daily intake

›Avoid excess alcohol

›Salt plan

›Avoid high salt foods

›Avoid added salt

›Medication plan

›Take diuretic exactly as prescribed

›Do not stop HF meds without clinician advice

›Follow up

›Primary care or HF clinic within 72 hours to 7 days

›Lab check for potassium and creatinine as directed

›Return now or call emergency services

›Trouble breathing at rest

›Chest pain

›Fainting or near fainting

›Blue lips or severe sweating with breathlessness

›Confusion or severe drowsiness

›SpO2 below personal target if home oximeter

›Weight gain

›>= 2 kg in 2 days

›>= 2.5 kg in 1 week

›Swelling rapidly worsening

›Not peeing much for 12 hours with swelling or breathlessness

12References/r24

Clinical guidelines and consensus

›Heart failure guidelines

›ACC AHA HFSA guideline for management of heart failure

›Class I recommendations for IV loop diuretics in congestion

›Disease modifying therapy framework for chronic HF

›ESC guideline for acute and chronic heart failure

›NIV support for cardiogenic pulmonary edema

›Vasodilator use in hypertensive pulmonary edema with adequate BP

›Cardiogenic shock guidance

›Society consensus statements on vasopressor choice

›Norepinephrine preferred first line in hypotensive shock

Evidence based sources

›Diuretic strategy trials

›DOSE trial

›Bolus versus infusion comparisons

›High dose versus low dose comparisons

›Adjunct decongestion trials

›ADVOR trial

›Acetazolamide plus loop diuretic improved decongestion

›NIV evidence

›Meta analyses in acute cardiogenic pulmonary edema

›Reduced intubation rates with CPAP or BiPAP

›Risk prediction tools

›ADHERE registry derivations

›EHMRG derivations and validations

›GWTG-HF risk score derivations

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.