acute decompensated heart failure
in review
7 min read
Updated 2026-03-25
Contents
acute decompensated heart failure — quick reference
Rapid assessment: profile the patient (warm/cold × wet/dry), identify precipitants, stabilise, decongest, and initiate/optimise GDMT before discharge. This note is the clinical approach overview. For detailed diuretic strategy and sequential nephron blockade, see diuretic therapy in acute heart failure.
ADHF admission bundle
- ABCs, sit upright, O₂ only if SpO₂ <90%
- IV access, cardiac monitor, 12-lead ECG
- labs: troponin, BNP/NT-proBNP, lytes, Cr, CBC, lactate, VBG
- CXR
- haemodynamic profile: warm/cold × wet/dry (Nohria-Stevenson)
- identify precipitant — FAILURES mnemonic
- IV furosemide dose by GFR (eGFR >45: 80 mg; 30–45: 120 mg; <30: 160–200 mg)
- spot urine Na⁺ at 2 h (target >50 mmol/L) — escalate if inadequate
- NIV (CPAP/BiPAP) if respiratory distress despite initial Rx
- NTG infusion if SBP >110 and flash pulmonary oedema
- start SGLT2i day 1 if SBP >100 and eGFR ≥20
- hold nephrotoxins: NSAIDs, reassess non-essential antihypertensives
- VTE prophylaxis
- daily weights, strict fluid balance
- initiate/resume GDMT (ARNi, BB, MRA) as haemodynamics allow
first 15 minutes
- ABCs — sit upright, supplemental O₂ if SpO₂ <90%
- IV access, cardiac monitor, 12-lead ECG
- rapid assessment: vitals (BP critical — drives entire approach), JVP, lung auscultation, peripheral perfusion
- investigations: troponin, BNP/NT-proBNP, lytes, Cr, CBC, lactate, VBG, CXR, ECG
- identify precipitants — treat immediately if found (see below)
haemodynamic profiling — Nohria-Stevenson
| warm (adequate perfusion) | cold (hypoperfusion) | |
|---|---|---|
| wet | warm & wet (most common ~65%) → diuretics ± vasodilators | cold & wet → inotropes + cautious diuretics |
| dry | warm & dry → reassess diagnosis, optimise GDMT | cold & dry → cautious volume challenge, inotropes |
the profile drives everything
SBP and perfusion status determine whether you vasodilate, diurese, or inotrope. Get this right first.
precipitants — “FAILURES”
| Cause | Immediate action | |
|---|---|---|
| F | forgot medications | restart GDMT |
| A | arrhythmia (AF most common), anaemia | rate/rhythm control; transfuse if Hb <70 |
| I | ischaemia/infarction, infection | ACS pathway; antibiotics |
| L | lifestyle (Na⁺/fluid excess) | counsel; diurese |
| U | upregulation (pregnancy, thyrotoxicosis) | treat underlying |
| R | renal failure | assess cardiorenal syndrome |
| E | embolism (PE) | CT-PA if suspected |
| S | stenosis (aortic) / valvular emergency | urgent echo; surgical/interventional assessment |
management by profile
warm & wet — vasodilate + diurese (SBP >110)
Vasodilators — reduce preload and afterload; rapid symptom relief in flash pulmonary oedema:
| Agent | Dose | Notes |
|---|---|---|
| NTG infusion | start 10–20 µg/min, titrate to BP | first-line if SBP >110; sublingual 0.4 mg q5min as bridge |
| NTG paste | 1–2 inches topical | slower onset; useful if IV access delayed |
| nitroprusside | 0.25–5 µg/kg/min | balanced vasodilator; use in hypertensive crisis + ADHF; requires arterial line; cyanide toxicity risk with prolonged use |
high-dose NTG for flash pulmonary oedema
Aggressive NTG (bolus 200–400 µg then infusion 100+ µg/min) can rapidly redistribute fluid out of the lungs in hypertensive flash oedema. More effective than furosemide in the first 30 minutes — the problem is fluid redistribution, not total body fluid excess.
Diuresis — see condensed algorithm below; full protocol in diuretic therapy in acute heart failure.
NIV — if respiratory distress despite initial measures:
- CPAP or BiPAP reduces intubation and improves symptoms — 3CPO (2008) showed no mortality benefit but reduced dyspnoea and need for intubation
- start CPAP 5–10 cmH₂O or BiPAP 10/5, titrate to work of breathing
- contraindications: unable to protect airway, vomiting, pneumothorax, SBP <85
warm & wet — diurese (SBP 90–110)
- IV loop diuretics as primary strategy
- avoid vasodilators if borderline BP
- hold/reduce non-essential antihypertensives to create “room” for GDMT
cold & wet — inotropes + cautious diuresis (SBP <90 or signs of hypoperfusion)
cardiogenic shock phenotype
Cold extremities, mottled skin, altered mentation, rising lactate, oliguria. This is not a diuretic problem — it’s a cardiac output problem. Diuretics alone will not work if forward flow is insufficient.
| Agent | Mechanism | Role |
|---|---|---|
| dobutamine | β₁ agonist → ↑ inotropy, ↑ HR | first-line inotrope; start 2–5 µg/kg/min |
| milrinone | PDE3 inhibitor → ↑ inotropy + vasodilation | useful if on BB (BB-independent); risk of hypotension; avoid in ischaemic CM — OPTIME-CHF (2002) |
| norepinephrine | α₁ + β₁ → ↑ SVR + inotropy | if SBP <80 or vasodilatory shock component; preferred over dopamine — SOAP II (2010) |
| epinephrine | α + β agonist | refractory shock; high arrhythmia risk |
| levosimendan | calcium sensitiser | not available in Canada; used in Europe for acute-on-chronic HF |
- add cautious loop diuretics once perfusion is restored
- early HF specialist / ICU involvement
- consider mechanical circulatory support (IABP, Impella, ECMO) if refractory
cold & dry — rare
- cautious 250 mL crystalloid bolus, reassess
- may need inotropes if no response
- consider RV failure (PE, RV infarct) — preload dependent
condensed diuresis algorithm
For the full natriuresis-guided protocol, electrolyte management, and trial evidence → diuretic therapy in acute heart failure
| Step | Action | Target |
|---|---|---|
| 1. Start | IV furosemide: dose by GFR (eGFR >45: 80 mg; 30–45: 120 mg; <30: 160–200 mg); give q12h | — |
| 2. Check 2h | spot urine Na⁺ | >50 mmol/L |
| 3. If inadequate | double dose or increase frequency | — |
| 4. Check 6h | cumulative urine output | >150 mL/h |
| 5. If still inadequate | add acetazolamide 500 mg IV (upfront prevention) | — |
| 6. If established resistance | add metolazone 2.5–5 mg PO 30 min before loop | — |
| 7. Rescue | KCl repletion for hypochloraemia → hypertonic saline if refractory | — |
do not wait for diuretic failure to start GDMT
SGLT2i can be started day 1 — EMPULSE (2022). ARNI, BB, MRA should be initiated or resumed as haemodynamics allow. Loops decongest; GDMT saves lives.
oxygen and ventilation
| SpO₂ | Action |
|---|---|
| >94% | no supplemental O₂ (hyperoxia may increase SVR and worsen afterload) |
| 90–94% | nasal prongs / simple mask |
| <90% or respiratory distress | NIV (CPAP/BiPAP) |
| failing NIV, exhaustion, unable to protect airway | intubation (use ketamine or etomidate — avoid propofol bolus in decompensated HF) |
ICU admission criteria
- cardiogenic shock or need for inotropes/vasopressors
- SBP <85 despite initial management
- respiratory failure requiring NIV or intubation
- acute mechanical complication (acute MR, VSD, free wall rupture)
- refractory arrhythmia
- acute coronary syndrome as precipitant requiring urgent intervention
discharge checklist
| Item | Detail |
|---|---|
| euvolaemia confirmed | stable weight on oral diuretics × 24–48h |
| GDMT optimised | all four pillars initiated or documented contraindication — STRONG-HF (2022) |
| oral diuretic dose set | double the effective IV dose for PO furosemide (50% bioavailability) |
| electrolytes stable | K⁺ >4.0, Mg²⁺ >0.8, Na⁺ >130 |
| daily weight instructions | weigh same time each morning; call if gain >2 kg in 2 days |
| follow-up booked | 1–2 weeks post-discharge for lytes, Cr, BP, GDMT titration |
| precipitant addressed | AF controlled, infection treated, adherence counselled |
| device eligibility flagged | if LVEF ≤35% — reassess after ≥3 months OMT |
| fluid / Na⁺ guidance | moderate Na⁺ restriction (<2000 mg/day); fluid restriction only if hyponatraemic |
| vaccination | influenza, COVID, pneumococcal if not up to date |