Evaluation of acute decompensated heart failure
- Duane S Pinto, MD, MPH
Duane S Pinto, MD, MPH
- Associate Professor of Medicine
- Harvard Medical School
- Robb D Kociol, MD
Robb D Kociol, MD
- Associate Director
- Advanced Heart Failure program
- Beth Israel Deaconess Medical Center
- Instructor in Medicine
- Harvard Medical School
Acute decompensated heart failure (ADHF) is a common and potentially fatal cause of acute respiratory distress. HF may be new or an exacerbation of chronic disease. The clinical syndrome is characterized by the development of acute dyspnea associated with the rapid accumulation of fluid within the lung's interstitial and alveolar spaces, which is the result of elevated cardiac filling pressures (cardiogenic pulmonary edema) . ADHF can also present as elevated left sided filling pressures and dyspnea without pulmonary edema. Less commonly, ADHF manifests as a low cardiac output state, characterized by fatigue, marked exercise intolerance, anorexia, and cognitive impairment.
Causes of ADHF include left ventricular systolic or diastolic dysfunction, changes in loading conditions, and valve disease.
Noncardiogenic pulmonary edema is a distinct clinical syndrome associated with diffuse filling of the alveolar spaces in the absence of elevated pulmonary capillary wedge pressure . Focused history, physical examination, echocardiography, laboratory analysis and, in some cases, direct measurement of pulmonary capillary wedge pressure can be used to distinguish cardiogenic from noncardiogenic pulmonary edema, as well as from other causes of acute respiratory distress. (See "Noncardiogenic pulmonary edema".)
“Flash” pulmonary edema is a term that is used to describe a particularly dramatic form of ADHF. In “flash” pulmonary edema, the underlying pathophysiologic principles, etiologic triggers, and initial management strategies are similar to those of less severe ADHF, although there is a greater degree of urgency to the implementation of initial therapies and the search for triggering causes. (See '"Flash" pulmonary edema' below.)
General issues related to the diagnosis of ADHF will be reviewed here. The pathophysiology, etiology, and treatment of ADHF and the evaluation of the clinically stable patient with suspected HF are presented separately. (See "Pathophysiology of cardiogenic pulmonary edema" and "Treatment of acute decompensated heart failure: General considerations" and "Evaluation of the patient with suspected heart failure".)
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- GENERAL APPROACH
- Clinical signs and symptoms
- Identification of precipitating factors
- - "Flash" pulmonary edema
- Chest radiography
- Laboratory data
- - Diagnostic utility of BNP and NT-proBNP
- Echocardiography and other imaging modalities
- Swan-Ganz catheter
- Coronary angiography
- DIFFERENTIAL DIAGNOSIS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS