A 70-year old man with past medical history of coronary artery disease with previous percutaneous coronary intervention (PCI), systolic heart failure (ejection fraction, 40%), poorly controlled type II diabetes mellitus, hypertension, and hyperlipidemia is admitted to the neurosurgical intensive care unit after resection of a meningioma. He was doing well postoperatively until overnight, when he suddenly developed shortness of breath.
The patient is found to be lethargic, tachypneic, tachycardic, and hypotensive with increased work of breathing. Cardiac examination reveals sinus tachycardia, S3 gallop, and an elevated jugular venous pulsation to the angle of the jaw. Bibasilar crackles are heard on lung auscultation. His lower extremities are cold and clammy with minimal pitting edema.
ECG demonstrates sinus tachycardia with old Q waves in inferior leads and new ST segment depressions in leads V4-V6. Chest radiograph reveals marked pulmonary vascular congestion bilaterally with cephalization.
The patient in this case is having an acute exacerbation of his chronic systolic heart failure termed acute decompensated heart failure (ADHF).
ADHF is a clinical syndrome defined by the acute onset of symptoms from heart failure due to congestion with or without a reduction in cardiac output.1 ADHF can be the initial presentation of heart failure, but more commonly the patient presents with an acute worsening of chronic heart failure. It reflects a disorder of myocardial dysfunction, although overall ejection fraction could be preserved. ADHF is the leading cause of cardiac-related hospital admissions in the United States.2 In addition, patients discharged after ADHF have high rates of unscheduled clinician visits and emergency department visits as well as 30-day readmission rates.3 Thus, ADHF represents a remarkable economic burden, drawing on an increasing portion of healthcare resources. There is emerging emphasis on comprehensive treatment strategies that are specifically tailored for ADHF management.
What are the essential considerations in the initial assessment of patients with ADHF, and how is ADHF classified?
Initial evaluation of ADHF should focus on assessment of the patient’s hemodynamic status as well as identification of any reversible causes of the exacerbation. A commonly used strategy is the rapid bedside assessment of volume and perfusion status of the patient, first described by Stevenson.4 Evaluation of volume status allows for assessment of the cardiac filling pressures to classify the patient as “wet” or “dry” and evaluation of adequacy of perfusion allows for assessment of end-organ perfusion to classify the patient as either “warm” or “cold.” Based on this evaluation, patients can then be divided into the following four profiles: warm and dry (profile A), warm and wet (profile B), cold and dry (profile L), and cold and wet (profile C)4 (Figure 37-1). This classification carries prognostic significance and also allows for targeted therapies according to each group.
Hemodynamic profiles. The four hemodynamic profiles of a patient with heart failure. ...