Acute decompensated heart failure
Encyclopedia
Acute decompensated heart failure (ADHF) is a common and potentially serious cause of acute respiratory distress.
. This most commonly results from an intercurrent illness (such as pneumonia
), myocardial infarction
(a heart attack), arrhythmias, uncontrolled hypertension
, or a patient's failure to maintain a fluid restriction, diet or medication. Other well recognised precipitating factors include anaemia and hyperthyroidism
which place additional strain on the heart muscle. Excessive fluid or salt intake, and medication that causes fluid retention such as NSAIDs
and thiazolidinedione
s, may also precipitate decompensation.
Acute myocardial infarction can precipitate acute decompensated heart failure and will necessitate emergent revascularization with thrombolytics, percutaneous coronary intervention, or coronary artery bypass graft.
is present; the Heart Failure Society of America, however, has recommended that it not be used routinely.
Even if symptoms of heart
failure are not present, medications can be used to treat the symptoms that are being experienced. These medicines work to control these symptoms as well as treat other health problems that might be present. They can work to improve the quality of life, slow down the progression of heart failure and reduce the risk for other complications that can occur due to heart failure. It's very important to take proper medicines exactly as prescribed by the physician.
A number of different medications are required for people whom are experiencing heart failure. Common types of medications that are prescribed for heart failure patients include ACE inhibitor
s, vasodilators
, beta blocker
s, blood thinners, calcium channel blocker
s, and cholesterol
lowering medications. Depending on the type of damage a patient has suffered and the underlying cause for the heart failure, any of these drug classes or a combination of them can be prescribed. Patients with heart pumping problems will use a different medication combination than those whom are experiencing problems with the heart filling. Potentially dangerous drug interactions can occur when different drugs mix together and work against each other. All medications have side effects. Many over-the-counter medications will cause a condition of heart failure to worsen.
Another option is nesiritide
, although it should only be considered if conventional therapy has been ineffective or contraindicated as it is much more expensive than nitroglycerine and has not been shown to be of any greater benefit.
Volume status should still be adequately evaluated. Some heart failure patients on chronic diuretics can be over diuresis. In the case of diastolic dysfunction without systolic dysfunction, fluid resuscitation may in fact improve circulation by decreasing heart rate, which will allow the ventricles more time to fill. Even if the patient is edematous, fluid resuscitation may be the first line of treatment if the patient is hypotensive. The patient may in fact be intravascularly volume depleted, although if the hypotension is due to cardiogenic shock
, additional fluid may make the situation worse. If the patient's circulatory volume is adequate but there is persistent evidence of inadequate end-organ perfusion, inotropes may be administered. In certain circumstances, a left ventricular assist device
(LVAD) may be necessary.
Once the patient is stabilized, attention can be turned to treating pulmonary edema to improve oxygenation. Intravenous furosemide is generally the first line. However, patients on long-standing diuretic regimens can become tolerant, and dosages must be progressively increased. If high doses of furosemide are inadequate, boluses or continuous infusions of bumetanide may be preferred. These loop diuretics may be combined with thiazide diuretics such as oral metolazone
or intravenous chlorthiazide for a synergistic effect. Intravenous preparations are preferred because of more predictable absorption. When a patient is extremely fluid overloaded, they can develop intestinal edema as well, which can affect enteral absorption of medications.
The effectiveness and safety of ACE inhibitor and angiotensin receptor blockers acutely in ADHF has not been studied, but is theoretically harmful. A person should be stabilized before therapy with either of these medication classes is commenced.
Beta-blockers
Beta-blockers are stopped or decreased in people with a low BP. However continuation of beta-blockers if the blood pressure is adequate may be appropriate.
Inotropic agents
Inotrope
s are indicated if hypotension ( BP < 90 ) is present.
Opiates
Opiates have traditionally been used in the treatment of the acute pulmonary edema that results from acute decompensated heart failure. A 2006 review however found little evidence to support this practice.
requires treatment with endotracheal intubation and mechanical ventilation
.
can be used to remove fluids in people with ADHF associated with renal failure. Studies have found that it decreases health care utilization at ninety days.
. Heart failure due to acute aortic regurgitation is a surgical emergency associated with high mortality. Heart failure may occur after rupture of ventricular aneurysm
. These can form after myocardial infarction. If it ruptures on the free wall, it will cause cardiac tamponade
. If it ruptures on the intraventricular septum, it can create a ventricular septal defect
. Other causes of cardiac tamponade may also require surgical intervention, although emergent treatment at bedside may be adequate. It should also be determined whether the patient had a history of a repaired congenital heart disease as they often have complex cardiac anatomy with artificial grafts and shunts that may sustain damage, leading to acute decompensated heart failure.
In some cases, doctors recommend surgery
to treat the underlying problem that led to heart failure. Different procedures are available depending on the level of necessity and include coronary artery bypass surgery
, heart valve
repair or replacement, or heart transplantation
. During these procedures, devices such as heart pumps, pacemakers
, or defibrillators
might be implanted. The treatment of heart disease is rapidly changing and thus new therapies for acute heart failure treatment are being introduced to save more lives from these massive attacks.
Bypass surgery is performed by removing a vein from the arm or leg, or an artery from the chest and replacing the blocked artery in the heart. This allows the blood to flow more freely through the heart. Valve repair is where the valve that is causing heart failure is modified by removing excess valve tissues that cause them to close too tightly. In some cases, annuloplasty
is required to replace the ring around the valves. If the repair of the valve isn't possible, it is replaced by an artificial heart valve
. The final step is heart replacement. When severe heart failure is present and medicines or other heart procedures are not effective, the diseased heart needs to be replaced.
Another common procedure used to treat heart failure patients is an angioplasty
. Is a procedure used to improve the symptoms of coronary artery disease (CAD), reduce the damage to the heart muscle after a heart attack
, and reduce the risk of death in some patients. This procedure is performed by placing a balloon in the heart to open an artery that is blocked by atherosclerosis
or a build up of plaque on the artery walls. Patients whom are experiencing heart failure because of CAD or recent heart attack, can benefit from this procedure.
A pacemaker is a small device that's placed in the chest or abdomen to help control abnormal heart rhythms. They work by sending electric pulses to the heart to prompt it to beat at a rate that is considered to be normal and are used to treat patients with arrhythmias. They can be used to treat hearts that are classified as either a tachycardia
that beats to fast, or a bradycardia
that beats too slow.
Causes
Chronic stable heart failure may easily decompensateDecompensation
In medicine, decompensation is the functional deterioration of a previously working structure or system. Decompensation may occur due to fatigue, stress, illness, or old age. When a system is "compensated," it is able to function despite stressors or defects. Decompensation describes an inability...
. This most commonly results from an intercurrent illness (such as pneumonia
Pneumonia
Pneumonia is an inflammatory condition of the lung—especially affecting the microscopic air sacs —associated with fever, chest symptoms, and a lack of air space on a chest X-ray. Pneumonia is typically caused by an infection but there are a number of other causes...
), myocardial infarction
Myocardial infarction
Myocardial infarction or acute myocardial infarction , commonly known as a heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die...
(a heart attack), arrhythmias, uncontrolled hypertension
Hypertension
Hypertension or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. What that means is that the heart is having to work harder than it should to pump the blood around the body. Blood pressure involves two measurements, systolic and...
, or a patient's failure to maintain a fluid restriction, diet or medication. Other well recognised precipitating factors include anaemia and hyperthyroidism
Hyperthyroidism
Hyperthyroidism is the term for overactive tissue within the thyroid gland causing an overproduction of thyroid hormones . Hyperthyroidism is thus a cause of thyrotoxicosis, the clinical condition of increased thyroid hormones in the blood. Hyperthyroidism and thyrotoxicosis are not synonymous...
which place additional strain on the heart muscle. Excessive fluid or salt intake, and medication that causes fluid retention such as NSAIDs
Non-steroidal anti-inflammatory drug
Nonsteroidal anti-inflammatory drugs, usually abbreviated to NSAIDs or NAIDs, but also referred to as nonsteroidal anti-inflammatory agents/analgesics or nonsteroidal Anti-inflammatory medicines , are drugs with analgesic and antipyretic effects and which have, in higher doses, anti-inflammatory...
and thiazolidinedione
Thiazolidinedione
The thiazolidinediones , also known as glitazones, are a class of medications used in the treatment of diabetes mellitus type 2. They were introduced in the late 1990s.- Mechanism of action :...
s, may also precipitate decompensation.
Acute myocardial infarction can precipitate acute decompensated heart failure and will necessitate emergent revascularization with thrombolytics, percutaneous coronary intervention, or coronary artery bypass graft.
Diagnosis
An jugular venous distension is the most sensitive clinical sign for acute decompensation.Treatment
In acute decompensated heart failure, the immediate goal is to re-establish adequate perfusion and oxygen delivery to end organs. This entails ensuring that airway, breathing, and circulation are adequate.Oxygen
Supplemental oxygen may be administered if hypoxemiaHypoxemia
Hypoxemia is generally defined as decreased partial pressure of oxygen in blood, sometimes specifically as less than or causing hemoglobin oxygen saturation of less than 90%.-Distinction from anemia and hypoxia:...
is present; the Heart Failure Society of America, however, has recommended that it not be used routinely.
Pharmacological
Initial therapy of acute decompensated heart failure usually includes some combination of a vasodilator such as nitroglycerine, a diuretic such as furosemide, and non invasive positive pressure ventilation (NIPPV).Even if symptoms of heart
Heart
The heart is a myogenic muscular organ found in all animals with a circulatory system , that is responsible for pumping blood throughout the blood vessels by repeated, rhythmic contractions...
failure are not present, medications can be used to treat the symptoms that are being experienced. These medicines work to control these symptoms as well as treat other health problems that might be present. They can work to improve the quality of life, slow down the progression of heart failure and reduce the risk for other complications that can occur due to heart failure. It's very important to take proper medicines exactly as prescribed by the physician.
A number of different medications are required for people whom are experiencing heart failure. Common types of medications that are prescribed for heart failure patients include ACE inhibitor
ACE inhibitor
ACE inhibitors or angiotensin-converting enzyme inhibitors are a group of drugs used primarily for the treatment of hypertension and congestive heart failure...
s, vasodilators
Vasodilation
Vasodilation refers to the widening of blood vessels resulting from relaxation of smooth muscle cells within the vessel walls, particularly in the large arteries, smaller arterioles and large veins. The process is essentially the opposite of vasoconstriction, or the narrowing of blood vessels. When...
, beta blocker
Beta blocker
Beta blockers or beta-adrenergic blocking agents, beta-adrenergic antagonists, beta-adrenoreceptor antagonists or beta antagonists, are a class of drugs used for various indications. They are particularly for the management of cardiac arrhythmias, cardioprotection after myocardial infarction ,...
s, blood thinners, calcium channel blocker
Calcium channel blocker
A calcium channel blocker is a chemical that disrupts the movement of calcium through calcium channels.CCB drugs devised to target neurons are used as antiepileptics. However, the most widespread clinical usage of calcium channel blockers is to decrease blood pressure in patients with...
s, and cholesterol
Cholesterol
Cholesterol is a complex isoprenoid. Specifically, it is a waxy steroid of fat that is produced in the liver or intestines. It is used to produce hormones and cell membranes and is transported in the blood plasma of all mammals. It is an essential structural component of mammalian cell membranes...
lowering medications. Depending on the type of damage a patient has suffered and the underlying cause for the heart failure, any of these drug classes or a combination of them can be prescribed. Patients with heart pumping problems will use a different medication combination than those whom are experiencing problems with the heart filling. Potentially dangerous drug interactions can occur when different drugs mix together and work against each other. All medications have side effects. Many over-the-counter medications will cause a condition of heart failure to worsen.
Vasodilators
Nitrates such as nitroglycerine are often used as part of the initial therapy for ADHF.Another option is nesiritide
Nesiritide
Nesiritide is the recombinant form of the 32 amino acid human B-type natriuretic peptide, which is normally produced by the ventricular myocardium...
, although it should only be considered if conventional therapy has been ineffective or contraindicated as it is much more expensive than nitroglycerine and has not been shown to be of any greater benefit.
Diuretics
Heart failure is usually associated with a volume overloaded state. Therefore those with evidence of fluid overload should be treated initially with intravenous loop diuretics. In the absence of symptomatic hypotension intravenous nitroglycerin is often used in addition to diuretic therapy to improve congestive symptoms.Volume status should still be adequately evaluated. Some heart failure patients on chronic diuretics can be over diuresis. In the case of diastolic dysfunction without systolic dysfunction, fluid resuscitation may in fact improve circulation by decreasing heart rate, which will allow the ventricles more time to fill. Even if the patient is edematous, fluid resuscitation may be the first line of treatment if the patient is hypotensive. The patient may in fact be intravascularly volume depleted, although if the hypotension is due to cardiogenic shock
Cardiogenic shock
Cardiogenic shock is based upon an inadequate circulation of blood due to primary failure of the ventricles of the heart to function effectively....
, additional fluid may make the situation worse. If the patient's circulatory volume is adequate but there is persistent evidence of inadequate end-organ perfusion, inotropes may be administered. In certain circumstances, a left ventricular assist device
Ventricular assist device
A Ventricular assist device, or VAD, is a mechanical circulatory device that is used to partially or completely replace the function of a failing heart...
(LVAD) may be necessary.
Once the patient is stabilized, attention can be turned to treating pulmonary edema to improve oxygenation. Intravenous furosemide is generally the first line. However, patients on long-standing diuretic regimens can become tolerant, and dosages must be progressively increased. If high doses of furosemide are inadequate, boluses or continuous infusions of bumetanide may be preferred. These loop diuretics may be combined with thiazide diuretics such as oral metolazone
Metolazone
Metolazone is a thiazide-like diuretic marketed under the brand names Zytanix from Zydus Cadila, Zaroxolyn, and Mykrox. It is primarily used to treat congestive heart failure and high blood pressure. Metolazone indirectly decreases the amount of water reabsorbed into the bloodstream by the kidney,...
or intravenous chlorthiazide for a synergistic effect. Intravenous preparations are preferred because of more predictable absorption. When a patient is extremely fluid overloaded, they can develop intestinal edema as well, which can affect enteral absorption of medications.
Other treatments
ACE inhibitors and ARBsThe effectiveness and safety of ACE inhibitor and angiotensin receptor blockers acutely in ADHF has not been studied, but is theoretically harmful. A person should be stabilized before therapy with either of these medication classes is commenced.
Beta-blockers
Beta-blockers are stopped or decreased in people with a low BP. However continuation of beta-blockers if the blood pressure is adequate may be appropriate.
Inotropic agents
Inotrope
Inotrope
An inotrope is an agent that alters the force or energy of muscular contractions. Negatively inotropic agents weaken the force of muscular contractions...
s are indicated if hypotension ( BP < 90 ) is present.
Opiates
Opiates have traditionally been used in the treatment of the acute pulmonary edema that results from acute decompensated heart failure. A 2006 review however found little evidence to support this practice.
Ventilation
Continuous positive airway pressure may be applied using a face mask; this has been shown to improve symptoms more quickly than oxygen therapy alone, and has been shown to reduce the risk of death. Severe respiratory failureRespiratory failure
The term respiratory failure, in medicine, is used to describe inadequate gas exchange by the respiratory system, with the result that arterial oxygen and/or carbon dioxide levels cannot be maintained within their normal ranges. A drop in blood oxygenation is known as hypoxemia; a rise in arterial...
requires treatment with endotracheal intubation and mechanical ventilation
Mechanical ventilation
In medicine, mechanical ventilation is a method to mechanically assist or replace spontaneous breathing. This may involve a machine called a ventilator or the breathing may be assisted by a physician, respiratory therapist or other suitable person compressing a bag or set of bellows...
.
Ultrafiltration
UltrafiltrationUltrafiltration
Ultrafiltration is a variety of membrane filtration in which hydrostatic pressure forces a liquid against a semipermeable membrane. Suspended solids and solutes of high molecular weight are retained, while water and low molecular weight solutes pass through the membrane...
can be used to remove fluids in people with ADHF associated with renal failure. Studies have found that it decreases health care utilization at ninety days.
Surgery
Certain scenarios will require emergent consultation with cardiothoracic surgeryCardiothoracic Surgery
Cardiothoracic surgery is the field of medicine involved in surgical treatment of diseases affecting organs inside the thorax —generally treatment of conditions of the heart and lungs .-Cardiac / Thoracic:...
. Heart failure due to acute aortic regurgitation is a surgical emergency associated with high mortality. Heart failure may occur after rupture of ventricular aneurysm
Ventricular aneurysm
Ventricular aneurysms are one of the many complications that may occur after a heart attack . They usually arise from a patch of weakened tissue in a ventricular wall, which swells into a bubble filled with blood. This, in turn, may block the passageways leading out of the heart, leading to...
. These can form after myocardial infarction. If it ruptures on the free wall, it will cause cardiac tamponade
Cardiac tamponade
Cardiac tamponade, also known as pericardial tamponade, is an emergency condition in which fluid accumulates in the pericardium ....
. If it ruptures on the intraventricular septum, it can create a ventricular septal defect
Ventricular septal defect
A ventricular septal defect is a defect in the ventricular septum, the wall dividing the left and right ventricles of the heart.The ventricular septum consists of an inferior muscular and superior membranous portion and is extensively innervated with conducting cardiomyocytes.The membranous...
. Other causes of cardiac tamponade may also require surgical intervention, although emergent treatment at bedside may be adequate. It should also be determined whether the patient had a history of a repaired congenital heart disease as they often have complex cardiac anatomy with artificial grafts and shunts that may sustain damage, leading to acute decompensated heart failure.
In some cases, doctors recommend surgery
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
to treat the underlying problem that led to heart failure. Different procedures are available depending on the level of necessity and include coronary artery bypass surgery
Coronary artery bypass surgery
Coronary artery bypass surgery, also coronary artery bypass graft surgery, and colloquially heart bypass or bypass surgery is a surgical procedure performed to relieve angina and reduce the risk of death from coronary artery disease...
, heart valve
Heart valve
A heart valve normally allows blood flow in only one direction through the heart. The four valves commonly represented in a mammalian heart determine the pathway of blood flow through the heart...
repair or replacement, or heart transplantation
Heart transplantation
A heart transplant, or a cardiac transplantation, is a surgical transplant procedure performed on patients with end-stage heart failure or severe coronary artery disease. As of 2007 the most common procedure was to take a working heart from a recently deceased organ donor and implant it into the...
. During these procedures, devices such as heart pumps, pacemakers
Artificial pacemaker
A pacemaker is a medical device that uses electrical impulses, delivered by electrodes contacting the heart muscles, to regulate the beating of the heart...
, or defibrillators
Defibrillation
Defibrillation is a common treatment for life-threatening cardiac arrhythmias, ventricular fibrillation and pulseless ventricular tachycardia. Defibrillation consists of delivering a therapeutic dose of electrical energy to the affected heart with a device called a defibrillator...
might be implanted. The treatment of heart disease is rapidly changing and thus new therapies for acute heart failure treatment are being introduced to save more lives from these massive attacks.
Bypass surgery is performed by removing a vein from the arm or leg, or an artery from the chest and replacing the blocked artery in the heart. This allows the blood to flow more freely through the heart. Valve repair is where the valve that is causing heart failure is modified by removing excess valve tissues that cause them to close too tightly. In some cases, annuloplasty
Intervertebral disc annuloplasty
The term intervertebral disc annuloplasty indicates any procedure aimed at repairing the annulus of a bulging intervertebral disc before it herniates.-Intradiscal electrothermal annuloplasty:...
is required to replace the ring around the valves. If the repair of the valve isn't possible, it is replaced by an artificial heart valve
Artificial heart valve
An artificial heart valve is a device implanted in the heart of a patient with heart valvular disease. When one of the four heart valves malfunctions, the medical choice may be to replace the natural valve with an artificial valve. This requires open-heart surgery.Valves are integral to the normal...
. The final step is heart replacement. When severe heart failure is present and medicines or other heart procedures are not effective, the diseased heart needs to be replaced.
Another common procedure used to treat heart failure patients is an angioplasty
Angioplasty
Angioplasty is the technique of mechanically widening a narrowed or obstructed blood vessel, the latter typically being a result of atherosclerosis. An empty and collapsed balloon on a guide wire, known as a balloon catheter, is passed into the narrowed locations and then inflated to a fixed size...
. Is a procedure used to improve the symptoms of coronary artery disease (CAD), reduce the damage to the heart muscle after a heart attack
Myocardial infarction
Myocardial infarction or acute myocardial infarction , commonly known as a heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die...
, and reduce the risk of death in some patients. This procedure is performed by placing a balloon in the heart to open an artery that is blocked by atherosclerosis
Atherosclerosis
Atherosclerosis is a condition in which an artery wall thickens as a result of the accumulation of fatty materials such as cholesterol...
or a build up of plaque on the artery walls. Patients whom are experiencing heart failure because of CAD or recent heart attack, can benefit from this procedure.
A pacemaker is a small device that's placed in the chest or abdomen to help control abnormal heart rhythms. They work by sending electric pulses to the heart to prompt it to beat at a rate that is considered to be normal and are used to treat patients with arrhythmias. They can be used to treat hearts that are classified as either a tachycardia
Tachycardia
Tachycardia comes from the Greek words tachys and kardia . Tachycardia typically refers to a heart rate that exceeds the normal range for a resting heart rate...
that beats to fast, or a bradycardia
Bradycardia
Bradycardia , in the context of adult medicine, is the resting heart rate of under 60 beats per minute, though it is seldom symptomatic until the rate drops below 50 beat/min. It may cause cardiac arrest in some patients, because those with bradycardia may not be pumping enough oxygen to their heart...
that beats too slow.