From Ohio Health, Riverside Methodist Hospital, Columbus, OH.
Abstract
Objective: To review the current in-hospital management of patients with acute decompensated heart failure (ADHF).
Methods: Review of the literature.
Results: Heart failure is a leading cause of hospitalization in the elderly, and morbidity, mortality, and hospital readmission rates for ADHF remain high. The patient’s hemodynamic status along with the use of prognostic models for short-term mortality may facilitate patient triage and encourage the use of evidence-based therapy, especially in high-risk patients. Initial treatment should target the relief of congestive symptoms, and intravenous loop diuretics are the mainstay of therapy. The preferred IV vasoactive medication has yet to be determined in a large prospective randomized trial. Positive inotropic agents should be reserved for patients with signs of low cardiac output and tissue hypoperfusion; however, the risk/benefit equation should be evaluated judiciously with each treatment option before initiating therapy. For patients with refractory hemodynamic collapse, ventricular assist devices can allow stabilization until recovery or decision regarding transplantation versus destination therapy.
Conclusion: Patients with ADHF are at increased risk for readmission to the hospital as well as at increased risk for death. Risk factors need to be identified and referral to a heart disease management program should be considered for those patients deemed at increased risk for rehospitalization.
Heart failure is a major public health problem in the United States and the leading cause of hospitalization in patients 65 years of age and older [1]. Patients hospitalized with acute decompensated heart failure (ADHF) have a readmission rate as high as 50% within 6 months and 25% within 30 days [2]. It is estimated that $32 billion is spent on heart failure care each year, the majority of which is directly related to inpatient care. Projections show that by 2030 the total cost of heart failure will increase to $70 billion per year [1]. Despite the growing burden, advances in treatment have been limited [2,3] and management continues to be a challenge. In this article, we review the current in-hospital management of patients with ADHF.
Case Study
Initial Presentation
A 64-year-old woman with a nonischemic dilated cardiomyopathy presents to the emergency department (ED) with a 4-day history of progressive dyspnea on exertion. She can not ambulate more than 50 feet without having to stop due to dyspnea and reports increased lower extremity edema. She is found to have a heart rate of 105 bpm, a respiratory rate of 30 breaths/min, and a blood pressure of 90/51 mm Hg. Physical examination is remarkable for distended neck vein, S3 gallop, end expiratory wheezing in the bases, and lower extremity edema. Blood tests, including a B-type natriuretic peptide level, are pending. Electrocardiogram and chest radiograph are ordered. The physician suspects that the patient has ADHF and admits her for further management.
What are aspects of initial management in the ED?
Most patients that present for evaluation and management of ADHF are first evaluated in the ED. Initial management includes an assessment of oxygenation, hemodynamic status, and adequacy of tissue perfusion, as well as for possibility of an acute coronary syndrome. A complete history, physical examination, chest radiography, 12-lead electrocardiogram, cardiac troponin T or I, electrolytes, and complete blood count should be obtained to allow rapid diagnosis and triage followed by prompt, aggressive treatment in the ED or observation unit. This should alleviate the patient’s symptoms sooner, and it is intuitive that this would lessen morbidity and length of hospital stay [4].
