ICU · Cardiovascular
Acute decompensated heart failure and cardiogenic pulmonary oedema
Also known as Acute decompensated heart failure (ADHF) · Cardiogenic pulmonary oedema · Flash pulmonary oedema · Acute heart failure (AHF)
Acute decompensated heart failure (ADHF) is a life-threatening syndrome of pulmonary and/or systemic congestion from cardiac dysfunction. Presentations: cardiogenic pulmonary oedema (acute breathlessness, orthopnoea, frothy sputum, bilateral crackles, hypoxia), cardiogenic shock (hypoperfusion — cold extremities, oliguria, altered mental status), or isolated right heart failure (peripheral oedema, raised JVP, hepatomegaly). Management: sit upright, high-flow oxygen, IV furosemide (1-2.5x usual oral dose), vasodilator (nitroglycerin if SBP 110), non-invasive ventilation (CPAP/BiPAP — reduces intubation and mortality). Identify and treat precipitant (ACS, arrhythmia, infection, non-adherence). Avoid beta-blockers acutely (negative inotropy).
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Red flags
- CPAP/BiPAP reduces mortality and intubation rates in cardiogenic pulmonary oedema — use EARLY
- Do NOT give beta-blockers in acute decompensated HF (negative inotropy) — may precipitate cardiogenic shock
- SBP <90 with pulmonary oedema = cardiogenic shock — different pathway (inotropes, mechanical support)
- Flash pulmonary oedema = consider bilateral renal artery stenosis (especially if AKI after ACE inhibitor)
Meet the patient
A 72-year-old man with known HFrEF (ejection fraction 30 percent) on bisoprolol, ramipril, spironolactone, and furosemide 80 mg daily is brought in at 4am sitting bolt upright, gasping, pink frothy sputum at his lips. His rate is 34, SpO2 84 percent on room air, BP 168 over 95, and he is in fast atrial fibrillation at 116. Bilateral coarse crackles rise to the apices, the JVP is at the angle of the jaw, and the chest X-ray shows bat-wing perihilar infiltrates with Kerley B lines.[1]
The two questions that decide his next hour are the two that decide every ADHF stem: is he perfused or shocky? (warm versus cold decides whether you reach for diuretics or for inotropes) and what tipped him over? (ACS, new AF, infection, non-adherence — the trigger you must find and fix). Hold those two questions and the Stevenson profile slots everything into place.[1]
References27ShowHide
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