Acute decompensated heart failure

Medical quality assurance by Dr. Albrecht Nonnenmacher, MD at December 16, 2016
StartDiseasesAcute decompensated heart failure

Acute decompensated heart failure, or ADHF is a condition where the symptoms of heart failure suddenly or gradually worsen. It is itself a cause of acute respiratory distress syndrome, which is an inflammation of the lungs.


Definition & Facts

Acute decompensated heart failure is a major reason why people visit emergency rooms, require hospitalization, or make unscheduled visits to their physicians. The incidence of ADHF is increasing worldwide as more people live to old age after having been successfully treated for previous heart problems. Over 20 million people are affected by ADHF worldwide. Of that number, 5 million live in the United States. It is the most common reason that people over the age of 65 are hospitalized.

Most people who are hospitalized for ADHF are men and women between 70 to 75 years old. Most of them have been treated for heart failure before, though about 15 to 20 percent are hospitalized for the first time. These first-time patients are more likely to have a condition where their heart suddenly can’t pump enough blood to serve their organs. This is called cardiogenic shock. In this case, a large area of the heart is simply not pumping or has actually ruptured.

Common reasons for hospitalization due to ADHF include diet; failure to properly take prescribed medications; and comorbid diseases such as diabetes mellitus, anemia, or chronic obstructive pulmonary disease that had suddenly worsened. Some people who are hospitalized due to ADHF have heart problems that have been exacerbated by side effects of medicines such as nonsteroidal anti-inflammatory drugs (NSAIDs) or calcium channel blockers.

Symptoms & Complaints

A classic symptom of ADHF is difficulty breathing that often worsens. People find that they are short of breath when they engage in physical activity. Some find it hard to breathe even when they are lying flat on their backs, and they may even wake up from sleep struggling for breath. Other people have a sudden attack of pulmonary edema that makes it hard to breathe.

Patients may also suffer heart palpitations and chest pain. Other symptoms and complaints are:

Patients with ADHF may find themselves waking up in the middle of the night to urinate but produce little urine. They may also become confused or have problems with their memory.


Patients with this condition often have a history of cardiovascular disease, high blood pressure, or kidney disease. People who have chronic but stable heart failure are at risk for ADHF. Heart failure is simply the heart’s inability to pump enough blood to bring oxygen to all the cells in the body. It can be caused by high blood pressure, a previous heart attack, alcoholism, infection, or one of several diseases of the cardiac muscle called cardiomyopathy. The ADHF may arise because the patient has had another heart attack or a disease like pneumonia.

Diagnosis & Tests

Physical examination of the patient and taking their family history and medical history are important parts of the diagnostic process. A medical professional can often tell that a patient is suffering from ADHF because their jugular vein is distended. They may have an unexplained weight gain, cool extremities, and pitting edema. This means when a finger is pressed into a swollen leg, the impression remains for a time.

A chest X-ray shows that their lungs are congested. Blood tests and electrocardiograms may also be conducted as part of the diagnostic process. Doctors have found that checking the levels of a hormone called BNP (brain natriuretic peptide) is helpful in diagnosing ADHF. The hormone is much higher in people who have heart failure than in patients who have trouble breathing for reasons unrelated to heart problems.

Patients should be hospitalized if they have severe symptoms of ADHF, and they should be monitored closely several times a day. This monitoring includes checking their blood pressure and oxygen saturation as well as their weight, their electrolytes, fluids, and their blood count. Tests to check liver function and a complete blood count should also be given. 

Treatment & Therapy

Treatment and therapy for a patient with ADHF depends on whether the heart failure is characterized by volume overload (in which the volume of blood exceeds the capacity of the heart to function) or low cardiac output. A patient who is suffering volume overload because of their ADHF is quickly put on diuretics such as furosemide. Diuretics cause excess fluids to be excreted from the body. Patients whose volume overload is severe can be given the drug along with vasodilators such as nitroglycerin or sodium nitroprusside. Vasodilators are often given intravenously.

Though diuretics can have side effects like dangerously low blood pressure (hypotension) and kidney damage, they are given to the sickest ADHF patients. Fortunately, most patients with volume overload respond well to diuretics. Patients who do not respond well to diuretics may be placed on dialysis. Patients with low cardiac output are given inotropic drugs such as milrinone or dobutamine. These drugs slow down heart muscle contractions but must be used carefully.

ADHF patients may also require vasopressin receptor antagonists to regulate their blood pressure. These drugs are aquaretics, which help the patient excrete excess water without losing necessary electrolytes. They have been shown to stabilize the patient’s weight, improve the circulation of their blood, and correct low levels of sodium. A hormone called relaxin shows promise when it comes to patients with ADHF by supporting the heart output and relieving shortness of breath.

Adenosine A(1) receptor antagonists were made to treat kidney disease, but they also seem to be of use with heart failure patients by reducing the side effects of drugs like furosemide. Ularitide is a chemically synthesized substance of urodilatin, a type of hormone that helps the circulation of the blood and eases heart failure symptoms in general.

Prevention & Prophylaxis

The best way to prevent acute decompensated heart failure is to maintain a healthy cardiovascular system. This needs to start at a young age and involves diet, regular exercise, and seeking prompt medical treatment for any conditions that may arise.