Figure 1.

Clinical assessment in ADHF should answer the two questions suggested by this diagram: First, does the patient present with significant congestion? Second, does the patient present with significant underperfusion? Using this construct, patients will segregate into one of four categories in accordance with clinical findings. Typically, patients move in a clockwise fashion through these categories, first becoming congested (warm and wet) and then vasoconstricted to maintain blood pressure (cold and wet). Once vasoactive support and diuresis is achieved, movement is generally counter-clockwise, from cold and wet, to warm and wet, and then warm and dry. However, some patients will remain underperfused despite restoration of normovolemia, representing the cold and dry group, for whom mechanical support may be needed [image redrawn from Kantor and Mertens (13)].