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Clinical Presentation and Management 169
of Acute Heart Failure

elevated jugular venous distention, hepatojugular re- severe peripheral hypoperfusion with subsequent
flux, hepatomegaly, ascites, and peripheral edema; end-organs damage; typically it is associated with
pleural effusions are often seen in patients with a low blood pressure (systolic BP < 90 mmHg) and low
previous history of chronic HF). urine output (< 0.5 mL/kg/min).
The sensitivity and specificity of symptoms and signs Acute Coronary Syndrome Complicated by Heart
to predict both clinical scenarios, i.e., elevated filling Failure: Up to 15% to 20% of patients admitted with
pressures or low cardiac output is often unsatisfac- ACS have signs and symptoms of heart failure and
tory, which leaves a relatively large margin of uncer- an additional 10% develop HF during hospital stay;
tainty to confirm the final diagnosis of AHF as well the incidence is even higher in reports focusing on
as need for additional investigations , which may patients with a diagnosis of AHF, where up to 40%
objectively also add to costs incurred. may have ACS as a precipitating factor ; interesting-
ly, ACS complicated by AHF is now often viewed as
Clinical Classifications: What the guidelines a separate clinical entity, characterized by complex
say about patient presentation structural, hemodynamic and neurohormonal inter-
actions, the need for urgent referral for coronary
According to the ESC guidelines,a patient with AHF intervention,confusing troponin positivity and poor
may present with one of the following clinical cate- outcome.
gories:
The updated AHA/ACC guidelines tend to indicate
Decompensated Chronic Heart Failure: When a pa- a lack of widely accepted nomenclature for HF syn-
tient with chronic HF develops progressive deterio- dromes requiring hospitalization and instead of ‘‘the
ration and worsening in signs and symptoms; periph- AHF patient’’ propose ‘‘the hospitalized HF patient’’
eral edema and/or pulmonary congestion are charac- with the following subgroup classification: a) patients
teristic for this clinical category; these patients may with acute coronary ischemia; b) patients with accel-
appear with low blood pressure which is often associ- erated hypertension with acutely decompensated
ated with impaired LVEF and predicts poor prognosis.
HF; c) patients with shock; d) patients with acutely
Pulmonary Edema: For many physicians, pulmo- worsening right HF; and e) patients with decompen-
nary edema is the real clinical presentation of AHF; sation after surgical procedures.
typically, signs and symptoms develop rapidly and
patients demonstrate severe respiratory distress with Clinical Profiling: Key for Therapeutic
tachypnea, orthopnea, and pulmonary congestion. Decisions in Acute Heart Failure
Hypertensive Heart Failure: Hypertensive heart fail- - AHF comprises a wide spectrum of clinical condi-
ure is associated with elevated blood pressure with tions ranging from gradual worsening of chronic
accompanying dyspnea and signs of pulmonary con- conditions (ie, peripheral edema and dyspnea) to
gestion, often in patients with relatively preserved pulmonary edema or cardiogenic shock. For clin-
LVEF. ical purposes, characterizing the patient’s clinical
profile at each phase of AHF management consti-
Isolated Right Heart Failure: Isolated right heart fail-
ure is characterized by low output syndrome in the tutes a key element for therapeutic decision-mak-
absence of pulmonary congestion, with low left ven- ing. In this context, the following clinical profiles
tricle filling pressures; importantly, a clear differenti- may be present:
ation is needed here between patients with chronic - Respiratory failure with inadequate ventilation and
HF who gradually develop signs and symptoms of peripheral oxygenation; in such cases, oxygen
right HF (elevated jugular venous pressure, peripher- should be administered; in more severe cases,
al edema, hepatomegaly, gut congestion), which at there may be a need for endotracheal intubation
some stage dominate the clinical picture vs patients and invasive ventilation.
with new-onset isolated right heart failure, often - Presence of life-threatening tachy- or bradyar-
secondary to either acute coronary syndrome (ACS) rhythmias with a need for urgent electrical cardio-
or pulmonary embolism; although the former does version or temporary pacing.
not fulfil the diagnostic criteria often with some pul-
monary congestion and elevated LV filling pressure - Peripheral hypoperfusion (typically with low systol-
many physicians tend to put such patients into this ic blood pressure, sometimes with a clinical picture
category. of cardiogenic shock); often there is a need for
inotropic agents, vasopressors or, in most severe
Cardiogenic Shock: Cardiogenic shock characterizes

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