Skip to main content
NCBI home page
Clinical Cardiology logoLink to Clinical Cardiology
. 2007 Jul 5;27(Suppl 5):1–9. doi: 10.1002/clc.4960271702

Rapid clinical assessment of hemodynamic profiles and targeted treatment of patient with acutely decompensated heart failure

Greegg C Fonarow 1,†,✉, Jim Edward Weber 2,✉
PMCID: PMC6654490

Abstract

Acutely decompensated heart failure (ADHF) is characterized by hemodynamic abnormalities and neurohormonal activation that contribute to heart failure (HF) symptoms, end‐organ dysfunction, arrhythmias, and progressive cardiac failure. The management of ADHF in the emergency department (ED) can be simplified and improved by a 2‐min bedside assessment that identifies any of four possible hemodynamic profiles on the basis of clinical signs and symptoms. The profiles are based on whether congestion is present or absent (wet or dry) and perfusion is adequate or limited (warm or cold). A wet‐warm profile is seen more frequently in the ED than any of the other three profiles (wet‐cold, dry‐warm, and dry‐cold). The four clinically determined profiles have been shown to predict clinical outcomes and may be used to guide initial HF therapy. The goals of treating ADHF are to stabilize the patient, reverse acute hemodynamic abnormalities, rapidly reverse dyspnea and/or hypoxemia caused by pulmonary congestion, and initiate treatments that will decrease disease progression and improve survival. An ideal agent for the wet‐warm profile would rapidly reduce pulmonary congestion, produce balanced arterial and venous dilation, promote natriuresis, lack direct positive inotropic effects, and not cause reflex neuroendocrine activation. Intravenous nesiritide in conjunction with loop diuretics has been found safe and effective as initial treatment for patients with the wet‐warm profile. For the wet‐cold profile, more intensive therapy and invasive hemodynamic monitoring may prove useful. This review will discuss the rapid clinical determination of hemodynamic profiles in patients presenting to the ED with ADHF and the options for their initial medical management. Case studies representing the wet‐warm, wet‐cold, dry‐warm, and dry‐cold profiles will be presented and discussed.

Keywords: acutely decompensated heart failure, bedside assessment, emergency department, hemodynamic profile, natriuretic peptide, vasodilators

Full Text

The Full Text of this article is available as a PDF (78.5 KB).

Contributor Information

Greegg C. Fonarow, Email: gfonarow@mednet.ucla.edu

Jim Edward Weber, Email: jwmd@umich.edu

References

  • 1. Hunt SA, Baker DW, Chin MH, Cinquegrani MP, Feldman AM, Francis GS, Ganiats TG, Goldstein S, Gregoratos G, Jessup ML, Noble RJ, Packer M, Silver MA, Stevenson LW: ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). 2001. American College of Cardiology website. Available at: http://www.acc.org/clinical/guidelines/failure/hf_index.htm [DOI] [PubMed]
  • 2. 2003 Heart and Stroke Statistical Update. Dallas, Tex.: American Heart Association, 2002. [Google Scholar]
  • 3. Nohria A, Lewis E, Stevenson LW: Medical management of advanced heart failure. J Am Med Assoc 2002; 287: 628–640 [DOI] [PubMed] [Google Scholar]
  • 4. Cody R: Clinical trials of diuretic therapy in heart failure: Research directions and clinical considerations. J Am Coll Cardiol 1993; 22 (4 suppl A ): 165A–171A [DOI] [PubMed] [Google Scholar]
  • 5. Fonarow GC: The treatment targets in acute decompensated heart failure. Rev Cardiovasc Med 2001; 2: 7–12 [PubMed] [Google Scholar]
  • 6. Gandhi SK, Powers JC, Nomier AM, Fowle K, Kitzman DW, Rankin KM, Little WC: The pathogenesis of acute pulmonary edema associated with hypertension. N Engl J Med 2001; 344: 17–22 [DOI] [PubMed] [Google Scholar]
  • 7. Fonarow GC, Hamilton MA, Moriguchi J, Creaser JW, Rourke DA: Hemodynamic predictors of clinical outcomes in decompensated advanced heart failure. J Cardiac Fail 2001; 7 (suppl 2): 038 [Google Scholar]
  • 8. Stevenson LW, Tillisch JH, Hamilton M, Luu M, Chelimsky‐Fallick C, Moriguchi J, Kobashigawa J, Walden J: Importance of hemodynamic response to therapy in predicting survival with ejection fraction less than or equal to 20% secondary to ischemic or nonischemic dilated cardiomyopathy. Am J Cardiol 1990; 66: 1348–1354 [DOI] [PubMed] [Google Scholar]
  • 9. Natriuretic Peptides in Health and Disease (Eds. Samson WK, Levin ER.). Totowa, N.J.: Humana Press, 1997. [Google Scholar]
  • 10. Cheng V, Kazanagra R, Garcia A, Lenert L, Krishnaswamy P, Gardetto N, Clopton P, Maisel A: A rapid bedside test for B‐type peptide predicts treatment outcomes in patients admitted for de‐compensated heart failure: A pilot study. J Am Coll Cardiol 2001; 37: 386–391 [DOI] [PubMed] [Google Scholar]
  • 11. Forrester JS, Diamond G, Chatterjee K, Swan HJ: Medical therapy of acute myocardial infarction by application of hemodynamic subsets (second of two parts). N Engl J Med 1976; 295: 1404–1413 [DOI] [PubMed] [Google Scholar]
  • 12. Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH, Stevenson LW: Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. J Am Coll Cardiol 2003; 41: 1797–1804 [DOI] [PubMed] [Google Scholar]
  • 13. Dries DL, Exner DV, Domanski MJ, Greenberg B, Stevenson LW: The prognostic implications of renal insufficiency in asymptomatic and symptomatic patients with ventricular systolic dysfunction. J Am Coll Cardiol 2000; 35: 681–689 [DOI] [PubMed] [Google Scholar]
  • 14. Hillege HL, Girbes AR, de Kam PJ, Boomsma F, de Zeeuw D, Charlesworth A, Hampton JR, van Veldhuisen DJ: Renal function, neurohormonal activation, and survival in patients with chronic heart failure. Circulation 2000; 102: 203–210 [DOI] [PubMed] [Google Scholar]
  • 15. Weinfeld MS, Chertow GM, Stevenson LW: Aggravated renal dysfunction during intensive therapy for advanced chronic heart failure. Am Heart J 1999; 138 (2 Pt. 1): 285–290 [DOI] [PubMed] [Google Scholar]
  • 16. Gottlieb SS, Abraham W, Butler J, Forman DE, Loh E, Massie BM, O'Connor CM, Rich MW, Stevenson LW, Young J, Krumholz HM: The prognostic importance of different definitions of worsening renal function in congestive heart failure. J Cardiol Fail 2002; 8: 136–141 [DOI] [PubMed] [Google Scholar]
  • 17. Kubo SH, Clark M, Laragh JH, Borer JS, Cody RJ: Identification of normal neurohormonal activity in mild congestive heart failure and stimulating effect of upright posture and diuretics. Am J Cardiol 1987; 60: 1322–1328 [DOI] [PubMed] [Google Scholar]
  • 18. Cotter G, Metzkor E, Kaluski E, Faigenberg Z, Miller R, Simovitz A, Shaham O, Marghitay D, Koren M, Blatt A, Moshkovitz Y, Zaidenstein R, Golik A: Randomised trial of high‐dose isosorbide dinitrate plus low‐dose furosemide versus high‐dose furosemide plus low‐dose isosorbide dinitrate in severe pulmonary edema. Lancet 1998; 351: 389–393 [DOI] [PubMed] [Google Scholar]
  • 19. Gottlieb SS, Brater DC, Thomas I, Havranek E, Bourge R, Goldman S, Dyer F, Gomez M, Bennett D, Ticho B, Beckman E, Abraham W: BG9719 (CVT‐124), an A1 adenosine receptor antagonist, protects against the decline in renal function observed with diuretic therapy. Circulation 2002; 105: 1348–1353 [DOI] [PubMed] [Google Scholar]
  • 20. Ewy GA: Inotropic infusions for chronic congestive heart failure: Medical miracles or misguided medicinals? J Am Coll Cardiol 1999; 33: 572–575 [DOI] [PubMed] [Google Scholar]
  • 21. Cuffe MS, Califf RM, Adams KF Jr, Benza R, Bourge R, Colucci WS, Massie BM, O'Connor CM, Pina I, Quigg R, Silver MA, Gheorghiade M: Short‐term intravenous milrinone for acute exacerbation of chronic heart failure. J Am Med Assoc 2002; 287: 1541–1547 [DOI] [PubMed] [Google Scholar]
  • 22. Fonarow GC, Chelimsky‐Fallick C, Stevenson LW, Luu M, Hamilton MA, Moriguchi JD, Tillisch JH, Walden JA, Albanese E: Effect of direct vasodilation with hydralazine versus angiotensin‐converting enzyme inhibition with captopril on mortality in advanced heart failure: The Hy‐C trial. J Am Coll Cardiol 1992; 19: 842–850 [DOI] [PubMed] [Google Scholar]
  • 23. Steimle AE, Stevenson LW, Chelimsky‐Fallick C, Fonarow GC, Hamilton MA, Moriguchi JD, Kartashov A, Tillisch JH: Sustained hemodynamic efficacy of therapy tailored to reduce filling pressures in survivors with advanced heart failure. Circulation 1997; 96: 1165–1172 [DOI] [PubMed] [Google Scholar]
  • 24. Fonarow GC, Stevenson LW, Walden JA, Livingston NA, Steimle AE, Hamilton MA, Moriguchi J, Tillisch JH, Woo MA: Impact of a comprehensive heart failure management program on hospital readmission and functional status of patients with advanced heart failure. J Am Coll Cardiol 1997; 30: 725–732 [DOI] [PubMed] [Google Scholar]
  • 25. Koller‐Strametz J, Wolzt M, Fuchs C, Putz D, Wisser W, Mensik C, Eichler HG, Laufer G, Schmetterer L: Renal hemodynamic effects of L‐arginine and sodium nitroprusside in heart transplant recipients. Kidney Int 1999; 55: 1871–1877 [DOI] [PubMed] [Google Scholar]
  • 26. VMAC Investigators : Intravenous nesiritide vs. nitroglycerin for treatment of decompensated congestive heart failure. J Am Med Assoc 2002; 287: 1531–1540 [DOI] [PubMed] [Google Scholar]
  • 27. Elkayam U, Johnson JV, Shotan A, Bokhari S, Solodky A, Canetti M, Wani OR, Karaalp IS: Double‐blind, placebo‐controlled study to evaluate the effect of organic nitrates in patients with chronic heart failure treated with angiotensin‐converting enzyme inhibition. Circulation 1999; 99: 2652–2657 [DOI] [PubMed] [Google Scholar]
  • 28. Levin ER, Gardner DG, Samson WK: Natriuretic peptides. N Engl J Med 1998; 339: 321–328 [DOI] [PubMed] [Google Scholar]
  • 29. Michaels AD, Klein A, Madden JA, Chatterjee K: Effects of intravenous nesiritide on human coronary vasomotor regulation and myocardial oxygen uptake. Circulation 2003; 107: 2697–2701 [DOI] [PubMed] [Google Scholar]
  • 30. Colucci WS, Elkayam U, Horton DP, Abraham WT, Bourge RC, Johnson AD, Wagoner LE, Givertz MM, Liang CS, Neibaur M, Haught WH, LeJemtel TH, for the Nesiritide Study Group: Intravenous nesiritide, a natriuretic peptide, in the treatment of decompensated congestive heart failure . N Engl J Med 2000; 343: 246–253 [DOI] [PubMed] [Google Scholar]
  • 31. Burger AJ, Elkayam U, Neibaur MT, Haught H, Ghali J, Horton DP, Aronson D: Comparison of the occurrence of ventricular arrhythmias in patients with acutely decompensated congestive heart failure receiving dobutamine versus nesiritide therapy. Am J Cardiol 2001; 88: 35–39 [DOI] [PubMed] [Google Scholar]
  • 32. Burger AJ, Horton DP, LeJemtel T, Ghali JK, Torre G, Dennish G, Koren M, Dinerman J, Silver M, Cheng ML, Elkayam U: Effect of nesiritide (B‐type natriuretic peptide) and dobutamine on ventricular arrhythmias in the treatment of patients with acutely decompensated congestive heart failure: The PRECEDENT study. Am Heart J 2002; 144: 1102–1108 [DOI] [PubMed] [Google Scholar]
  • 33. Peacock F, Emerman CL, Costanzo MR, Berkowitz RL, Cheng M: Early initiation of intravenous vasoactive therapy improves heart failure outcomes: An analysis from The ADHERE Registry database. Ann Emerg Med 2003; 42 (4): S26 [Google Scholar]

Articles from Clinical Cardiology are provided here courtesy of Wiley

RESOURCES