Clinical Presentation

Patients with ADHF may present in one of four hemodynamic subsets based on volume status (euvolemic or “dry” vs volume overloaded or “wet”) and cardiac output (adequate cardiac output or “warm” vs hypoperfusion or “cold”).

Volume overload: dyspnea, orthopnea, paroxysmal nocturnal dyspnea, ascites, gastrointestinal symptoms (poor appetite, nausea, early satiety), peripheral edema, weight gain.

Low output: altered mental status, fatigue, gastrointestinal symptoms (similar to volume overload), decreased urine output.

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Generalized Symptoms:

• Dyspnea – Progressive exertional dyspnea is hallmark, can worsen to orthopnea and occur at rest
• Fatigue, weakness – Impaired cardiac output limits physical activity
• Peripheral edema – Systemic venous congestion causes bilateral lower extremity pitting edema
• Paroxysmal nocturnal dyspnea – Orthopnea with sudden awakening from sleep gasping for air
• Abdominal discomfort, nausea – Systemic and bowel wall venous congestion

Signs:

• Tachypnea – Respiratory rate >20 breaths/min suggests impaired gas exchange from pulmonary edema
• Tachycardia – Heart rate >100 bpm compensates for poor cardiac output
• Hypotension – Systolic BP <90 mmHg suggests impaired perfusion
• Hypertension – Systolic BP >180 mmHg from neurohormonal activation
• Jugular venous distension – Height >3 cm suggests elevated right heart pressures
• Pulmonary rales – Crackles on lung auscultation indicate extravascular lung water
• S3 heart sound – Third heart sound reflects increased left ventricular filling pressure
• Peripheral edema – Bilateral lower extremities, sacral edema in supine patients
• Hepatomegaly – Enlarged tender liver suggests passive venous congestion

Risk Factors:

• Older age
• Male sex
• Reduced ejection fraction
• Ischemic heart disease
• Diabetes
• Chronic kidney disease
• Anemia
• High dietary sodium intake
• Lack of guidelinedirected medical therapy
• Low socioeconomic status

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Laboratory Values

Volume overload: B-type natriuretic peptide <100 pg/mL (ng/L; 29 pmol/L) and N-terminal B-type natriuretic peptide <300 pg/mL (ng/L; 35 pmol/L) are negatively predictive for congestive ADHF; serum sodium concentration <130 mEq/L (mmol/L); elevated alkaline phosphatase; elevated gamma-glutamyl transferase.

Low cardiac output: evidence of end-organ injury due to impaired perfusion, such as elevated liver transaminases and serum creatinine; mixed venous oxygen concentration <60% (0.60); elevated serum lactate.

Hemodynamic Monitoring

Volume overload: pulmonary capillary wedge pressure >18 mm Hg; other volumetric pressures (e.g. right atrial pressure, pulmonary artery diastolic pressure) are also commonly elevated.

Low cardiac output: cardiac index <2.2 L/min/m2 (0.037 L/s/m2), with or without systemic vascular resistance >1,400 dyne·sec·cm−5 (18 Wood units; 140 MPa·s/m3).