Acute Decompensated Heart Failure: Causes, Symptoms, Treatment, Surgery, Medications

Acute decompensated heart failure (ADHF) is a condition where the patient experiences sudden deterioration of the signs and symptoms of an existing heart failure. These include dyspnea (difficulty in breathing), swelling in feet or legs and fatigue. Acute decompensated heart failure is a common and a serious cause for acute respiratory distress. This condition occurs as a result of severe congestion of multiple organs due to inadequate circulation of the fluid by the failing heart. The attack of decompensation occurs due to underlying illnesses, such as myocardial infarction, thyroid disease or infection.

Treatment of acute decompensated heart failure comprises of decreasing the level of fluid using diuretics; and improving the function of the heart with the use of nitrates or levosimendan. Aquapheresis ultra-filtration treatment can also be done if needed.

The cause of decompensation can be chronic heart failure. This occurs due to intercurrent illness like pneumonia, abnormal heart rhythms, myocardial infarction, uncontrolled hypertension or failure to adhere to fluid restriction, medication or diet. Other causes of Acute Decompensated Heart Failure include hyperthyroidism and anemia, which puts additional strain on the muscles of the heart.

Acute myocardial infarction can bring on acute decompensated heart failure and requires emergent revascularization with thrombolytics, coronary artery bypass graft or percutaneous coronary intervention.

Excessive salt or fluid intake and certain medications, such as NSAIDs, which cause fluid retention and thiazolidinediones, can also precipitate decompensation.

Patient suffering from acute decompensated heart failure has difficulty in breathing, which is the primary symptom of left ventricular failure. This condition becomes more profound by progressively worsening symptoms that occurs as the following:

• Orthopnea, which is difficulty in breathing when lying flat.
• Exertional dyspnea, which is difficulty in breathing with any physical activity.
• Paroxysmal nocturnal dyspnea, where the patient wakes up from sleep gasping for air.
• Acute pulmonary edema.
• Other cardiac symptoms include palpitations and chest pressure/pain.

• Nausea.
• Loss of appetite.
• Weight loss.
• Fatigue.
• Bloating.
• Weakness.
• Decreased urine output.
• Nocturia or frequently urinating at night.
• Cerebral symptoms, such as anxiety, confusion and impairment of memory.

A jugular venous distention is the most precise objective sign for Acute Decompensated Heart Failure.

The immediate goal in treatment of acute decompensated heart failure is re-establishing sufficient perfusion and delivery of oxygen to the end organs. This requires ensuring that the patient is getting or having adequate circulation, breathing and airway. Other management options comprise:

• Propping up the patient’s head.
• Morphine administration.
• Administering oxygen for correction of hypoxemia.
• Diuretics such as furosemide.
• Use of nitrates, ACE inhibitor and digoxin.
• Supplemental oxygen is given to the patient if hypoxemia is present; however, it is not recommended that this should be given on a regular basis.

Medications in acute decompensated heart failure which is in the initial stage include combination of a diuretic, such as furosemide, vasodilator such as nitroglycerin and NIPPV which is non-invasive positive pressure ventilation.

If the patient is not having symptoms of heart failure, then medications are given for the symptoms which are being experienced by the patient to help control symptoms along with treating other health issues which may be present. Medications also help in improving the quality of life of the patient, curbing the progression of heart failure and cutting the risk of complications associated with heart failure. It is important that the patient suffering from acute decompensated heart failure takes the right medicines and in the manner in which the physician has prescribed.

There are different types of medications for heart failure which include ACE inhibitors, beta blockers, vasodilators, aspirin, statins and calcium channel blockers. The type of drug used or a combination of different medicines which can be used depends on the underlying cause of the heart failure and the damage suffered by the patient. Some of the medications, which are used in treating acute decompensated heart failure, are:

Vasodilators: These include nitrates, such as nitroglycerin and are commonly used initially for treating ADHF. Nesiritide can also be used if conventional therapy is contraindicated or ineffective. Nesiritide is more expensive than nitroglycerine and does have the same amount of benefit.

Diuretics: Heart failure commonly occurs as result of fluid overload in the body. Therefore, intravenous loop diuretics are given in patients who exhibit symptoms of volume overload. If the patient does not have symptomatic hypotension, then intravenous nitroglycerin is commonly given in combination with diuretic therapy in order to alleviate congestive symptoms.

It is important to evaluate the volume status of the patient, as there is a risk of being over diuresed in patients with heart failure who are on chronic diuretics. If the patient only has diastolic dysfunction, then fluid resuscitation helps in improving the circulation by slowing the heart rate. This gives more time to the ventricles to fill. In cases where the patient is edematous, but hypotensive, fluid resuscitation can be the first line of treatment.

If the cause of hypotension in a patient is cardiogenic shock, then excessive fluid will worsen the situation. If the circulatory volume of the patient is adequate, but there is inadequate end-organ perfusion, then in such cases inotropes can be administered. In some situations, LVAD or left ventricular assist device becomes necessary.

After the patient suffering from acute decompensated heart failure has been stabilized, treating the pulmonary edema for improving oxygenation becomes the main focus. The first line of treatment in such a case is administering intravenous furosemide. However, acute decompensated heart failure patients who are on chronic diuretics tend to become tolerant, so in such cases, the dosage needs to be progressively increased. If the high doses of furosemide are not effective, then boluses or continuous infusions of bumetanide are recommended. Combination of loop diuretics with thiazide diuretics can also be given for additional effect.

Beta-Blockers: Patients having low blood pressure need to stop the beta-blockers or the dosage needs to be reduced. If the blood pressure is adequate, then the beta-blockers can be safely continued.

Inotropes: Inotropic agents are given if the patient is suffering from hypotension, i.e. if the BP is less than 90.

Opiates: Opiates are frequently used for treating acute pulmonary edema which occurs as a result of acute decompensated heart failure.

ACE Inhibitors & ARBs: The safety and efficacy of ACE inhibitor and angiotensin receptor blockers in treatment of acute decompensated heart failure is not well studied. However, these medications can be potentially harmful. It is important that the patient is stabilized before starting treatment with any of these classes of medications. There is a risk for kidney impairment in patients having poor kidney perfusion, which is a characteristic of these medications.

• Ventilation: Continuous positive airway pressure (CPAP) is more beneficial in rapidly improving the symptoms when compared to oxygen therapy alone. CPAP also decreases the risk of death. Endotracheal intubation and mechanical ventilation is required in severe respiratory failure.
• Ultrafiltration: Ultrafiltration is used for removing fluids in patients who are having acute decompensated heart failure associated with kidney failure.

In certain situations, necessity may arise which requires consultation with cardiothoracic surgery and these situations are:

• Patients having heart failure from acute aortic regurgitation need immediate surgery, as this is a highly fatal situation.
• Rupture of ventricular aneurysm, which can form after myocardial infarction, can also lead to heart failure. If the aneurysm ruptures on the free wall, it results in cardiac tamponade. If the aneurysm has ruptured on the interventricular septum, it may result in a ventricular septal defect.
• Cardiac tamponade occurring from other causes can also need surgical intervention; however, in some cases, emergent bedside treatment may be sufficient.
• It is also important to find out if the patient has had a previous history of a repaired congenital heart disease, as these patients commonly have complex cardiac anatomy with shunts and artificial grafts, which may incur damage resulting in acute decompensated heart failure.
• In some patients, surgery is recommended for treating the underlying problem, which has caused acute decompensated heart failure.

There are different procedures available, which can be done depending on the requirement of the patient. These surgical procedures include heart valve repair or replacement, coronary artery bypass surgery or heart transplantation. Different devices can be implanted during these procedures, such as pacemakers, heart pumps or defibrillators .

Some of the surgical procedures done in Acute Decompensated Heart Failure are:

• Bypass Surgery: In this procedure, artery from the chest or a vein from the arm or leg is removed and is used to replace the blocked artery in the heart. This permits free circulation of the blood through the heart.
• Valve Repair: In this procedure, the valve responsible for heart failure is changed by cutting off the excess valve tissues, which are causing the valve to close too tightly. If valve repair is not possible, then an artificial heart valve is placed instead.
• Annuloplasty: This is a procedure where the ring surrounding the valves is replaced. Heart replacement is done as the final resort where the patient has severe heart failure and is not benefitting from medicines or other heart procedures. In such cases, replacement of the diseased heart is done.
• Angioplasty is a common procedure which is done for treating heart failure. This procedure is also done for reducing the damage to the heart muscle after the patient has had a heart attack, for improving the symptoms of coronary artery disease and to cut down on the risk of death in some patients. In angioplasty, a balloon is placed in the heart in order to widen the artery, which is blocked by buildup of plaque or atherosclerosis. Patients suffering from heart failure due to coronary artery disease also benefit from angioplasty.
• Pacemaker is a device, which helps in controlling abnormal heart rhythms. It is placed in the chest or abdomen and works by transmitting electric impulses to stimulate the heart so that it can beat at a normal rate. Pacemaker also helps patients who have arrhythmias. Pacemakers can also be used for treating heart rates that are too fast (tachycardia) or too slow (bradycardia).

There are many new treatments undergoing research for heart disease and new therapies are being introduced for treating acute heart failure to save more and more patients from these types of massive attacks.