Acute Decompensated Heart Failure
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Direct answer
Acute decompensated heart failure is a rapid worsening of heart failure requiring hospital care, usually from congestion with or without poor peripheral perfusion. The Stevenson (Nohria-Stevenson) profile sorts patients into wet or dry according to congestion and warm or cold according to perfusion, and the profile dictates therapy: intravenous loop diuretics for congestion, vasodilators when afterload is high, and inotropes when cardiac output fails.
What you must remember
- Warm and wet: the commonest profile, with congestion and adequate perfusion; treated with an intravenous loop diuretic and a vasodilator if blood pressure allows.
- Cold and wet: congestion with hypoperfusion; needs an inotrope such as dobutamine, cautious vasodilator use and urgent evaluation for cardiogenic shock.
- Warm and dry: no congestion and good perfusion, so aggressive diuresis is inappropriate; the precipitant is sought rather than the fluid removed.
- Cold and dry: low output without congestion, where a cautious fluid challenge may be tried before inotropes are considered.
- Loop diuretics: intravenous furosemide is the usual agent, with the initial intravenous dose at least equal to the usual oral daily dose; urine output and weight guide escalation, and resistance may need a thiazide add-on or ultrafiltration.
- Vasodilators: intravenous nitroglycerin reduces preload at low dose and afterload at higher dose; nitroprusside suits refractory pulmonary oedema but needs close monitoring for hypotension and cyanide.
- Inotropes: dobutamine is the usual first choice; milrinone causes vasodilation, hypotension and is renally cleared, so it needs caution in low blood pressure.
A cold and wet patient on the medical ward
A 67-year-old man with a known ejection fraction of 25 per cent presents breathless, with blood pressure 92 over 60 mmHg, cold peripheries, a raised jugular venous pressure, an S3 and rising creatinine. Lactate is raised. The profile is cold and wet, and the first decision is to avoid vasodilators, because low pressure leaves no margin for afterload reduction. Instead, dobutamine is started under monitoring, with an arterial line where available, and a loop diuretic is given cautiously to relieve congestion without precipitating further hypotension.
The second decision is the precipitant. An ECG and troponin look for acute ischaemia, an arrhythmia such as atrial fibrillation is checked for, and infection, thyroid dysfunction and recent drug changes are reviewed. Sodium and potassium are monitored, as aggressive diuresis causes both. Renal function guides the diuretic dose, and a worsening creatinine does not automatically mean stopping decongestion. If pressure fails despite inotrope support, mechanical circulatory support or cardiology referral is the next step. The lesson is that the profile, not the symptom, decides the drug.
Where the exam tries to catch you
Examiners test the vasodilator rule. Nitrates and nitroprusside are excellent in warm, hypertensive pulmonary oedema, but giving them to a cold, hypotensive patient causes collapse. Morphine is no longer routinely used for pulmonary oedema, because it can depress ventilation and provides no lasting benefit. The second trap is beta blockers: they are not started during decompensation, though patients already on them are usually continued unless they are in cardiogenic shock.
In Indian wards, the frequent error is treating every breathless patient as a fluid overload and pushing diuretics without checking perfusion. A warm, dry patient given aggressive diuresis may become hypovolaemic and develop acute kidney injury. The viva answer always starts with perfusion and congestion, because those two findings select the entire therapy.
Frequently asked questions
What does warm and wet mean in acute decompensated heart failure?
Warm and wet describes a patient who is congested but adequately perfused, which is the commonest profile. Intravenous loop diuretics and a vasodilator such as nitroglycerin are the usual treatment, provided blood pressure allows.
Which inotrope is preferred in cold and wet heart failure with hypotension?
Dobutamine is usually preferred in cold and wet heart failure, because it increases contractility with less vasodilation than milrinone. Milrinone is an alternative, but it can worsen hypotension, and norepinephrine is added when pressure must be supported.
Why are intravenous loop diuretics preferred for pulmonary oedema?
Intravenous furosemide causes venodilation within minutes, reducing preload before diuresis develops, so pulmonary oedema eases faster than with oral dosing. The diuretic effect then provides lasting decongestion over the following hours.
Should beta blockers be started during acute decompensated heart failure?
Beta blockers should not be started during acute decongestion, because they can precipitate further pump failure in a patient already decompensated. Patients already on them are usually continued unless they are in cardiogenic shock, and initiation is deferred until the patient is stable.