ICU · Cardiovascular

Acute decompensated heart failure: NIV, diuretics, inotropes, and MCS in ICU

Also known as ADHF · Acute heart failure · Cardiogenic pulmonary oedema · Flash pulmonary oedema · Acute decompensated HF

Acute decompensated heart failure (ADHF) = sudden worsening of heart failure → pulmonary oedema and/or systemic congestion. PRECIPITANTS: ACS, arrhythmia (AF), infection, non-adherence (medications/diet), renal failure, anaemia, thyroid, drugs (NSAIDs, calcium channel blockers). CLASSIFICATION: (1) 'WARM AND WET' (most common — pulmonary oedema + preserved perfusion — BP normal/high) → vasodilators + diuretics. (2) 'COLD AND WET' (cardiogenic shock — hypoperfusion + congestion — hypotensive) → inotropes + diuretics ± MCS. (3) 'WARM AND DRY' (compensated). (4) 'COLD AND DRY' (low output, no congestion). MANAGEMENT: (1) NIV (CPAP/BiPAP — 3CPO trial — faster relief of dyspnoea and metabolic disturbance; no difference between CPAP and BiPAP; no effect on short-term mortality). (2) DIURETICS (frusemide IV — 1-2.5x usual oral dose — DOSE trial: high vs low dose — no difference in symptoms or renal function; continuous vs bolus — no difference). (3) VASODILATORS (nitroglycerin for the hypertensive congested patient — reduce preload/afterload). (4) INOTROPES (if cold — dobutamine, milrinone — bridge only: PROMISE and OPTIME-CHF). (5) MCS (IABP, Impella, VA-ECMO — if refractory shock — IABP-SHOCK II: no routine IABP). (6) IDENTIFY + TREAT PRECIPITANT (ACS → PCI; AF → cardioversion; infection → antibiotics). AVOID: beta-blockers acutely (negative inotrope — may worsen), calcium channel blockers (negative inotrope), NSAIDs (sodium retention), routine morphine (ADHERE: associated with worse outcomes), routine ultrafiltration (CARRESS-HF). INITIATE GDMT (four pillars) once stabilised (MERIT-HF, CIBIS-II, COPERNICUS).

Checked against its sources on 11 Sept 2026