Diagnostic Approach

• Electrocardiogram: Evaluate for arrhythmias, ischemic changes, QRS morphology and duration
• Chest X-ray: Assess for pulmonary vascular redistribution, pleural effusions, cardiomegaly
• Echocardiography:
  • Ejection fraction: Differentiate HFrEF (<40%) vs HFpEF (≥50%)
  • Structural analysis: Valvular disorders, wall motion abnormalities
• Laboratory tests:
  • Complete blood count: Anemia, infection
  • Basic metabolic panel: Electrolytes, renal function
  • Troponin: Detect myocardial infarction as precipitant
  • Natriuretic peptides: BNP >400 pg/mL or NT-proBNP >2000 pg/mL supports ADHF diagnosis
  • Additional tests: Venous oxygen saturation, serum lactate, iron studies

• Consider right heart catheterization:
  • Warm and wet: PCWP >18 mmHg, CI >2.2 L/min/m2
  • Cold and wet: PCWP >18 mmHg, CI <2.2 L/min/m2
  • Cold and dry: PCWP <15 mmHg, CI <2.2 L/min/m2

Hemodynamic Profiles Patients can be classified into four hemodynamic profiles based on volume status and cardiac output:

1. Warm and Dry: Euvolemic, normal cardiac output
2. Warm and Wet: Hypervolemic, normal cardiac output
3. Cold and Dry: Hypovolemic, reduced cardiac output
4. Cold and Wet: Hypervolemic, reduced cardiac output