Acute Heart Failure & Pulmonary Edema

• Wet & cold (congestion + hypoperfusion) → inotrope ± pressor — ICU; wet & warm (congested, perfused) → IV furosemide ± vasodilators.
• IV diuretic dose ≥ home oral dose; track urine output/weight daily; ultrafiltration if diuretic-resistant.
• Keep the β-blocker going if perfusion is adequate; hold ACEi/ARNI when hypotensive; starting an SGLT2i in hospital improves outcomes.
• Look for precipitants (ischemia, AF, non-adherence, infection) and treat them in parallel.

Stepwise Approach to Acute Decompensated Heart Failure

• Heart failure, acutely decompensated
• Pulseless or breathless?
• BLS/ACLS
• Pain or distress?
• Consider analgesics or sedatives to lower sympathetic drive
• Hypoxemia?
• Raise inspired oxygen fraction (FiO₂); consider BiPAP (or elective intubation)
• Arrhythmia?
• Control rate and rhythm (e.g., pacing, DCCV, amiodarone)
• Adequate BP (MAP >65)?
• Vasodilators ± diuretics if volume overloaded
• Hypovolemia?
• Volume resuscitation
• Hypoperfusion signs (e.g., metabolic acidosis, low SvO₂)?
• Inotropes ± short-term mechanical support
• Frequent monitoring; consider PA catheter if instability persists

Acute Decompensated Heart Failure Therapies by Clinical Profile (Forrester

• Classification rests on cardiac index (CI 2.2 L/min/m² — tissue perfusion) together with pulmonary capillary wedge pressure (PCWP 18 mm Hg — pulmonary edema)
• Class I — CI normal/high + PCWP low: normal; Rx: chronic HF therapy
• Class II — CI normal/high + PCWP high: pulmonary edema; Rx: diuretics, vasodilators
• Class III — CI low + PCWP low: hypovolemic shock; Rx: volume repletion
• Class IV — CI low + PCWP high: cardiogenic shock; low BP → inotropes, pressors · normal BP → vasodilators