Acute heart failure
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Acute Heart Failure: Pathophysiology, Diagnosis, and Management
Introduction to Acute Heart Failure
Acute heart failure (AHF) is a syndrome characterized by the sudden onset or rapid worsening of heart failure symptoms, primarily due to systemic congestion. It can manifest as either de novo heart failure or acutely decompensated chronic heart failure (ADHF). The condition is often precipitated by underlying cardiac dysfunction, which may be chronic or previously undiagnosed, and can be triggered by factors such as acute coronary syndrome.
Pathophysiology of Acute Heart Failure
The pathophysiology of AHF is complex and heterogeneous, involving both systolic and diastolic dysfunction of the left ventricle, leading to increased preload and afterload, and resulting in pulmonary and systemic congestion . This congestion can cause organ dysfunction due to hypoperfusion. Key mechanisms include endothelial dysfunction, neurohormonal activation, venous congestion, and myocardial injury. Additionally, comorbid conditions such as lung and renal disease, and sleep-disordered breathing, can exacerbate AHF.
Diagnostic Challenges and Tools
Diagnosing AHF in the emergency department can be challenging, especially in patients presenting with undifferentiated dyspnea. Effective diagnostic tools include physical examination, chest radiographs, lung ultrasound, and biomarkers like B-type natriuretic peptide (BNP) and N-terminal proB-type natriuretic peptide (NT-proBNP). Lung ultrasound and bedside echocardiography are particularly useful for confirming AHF, while low levels of BNP and NT-proBNP are valuable for excluding the diagnosis.
Management Strategies
Symptomatic Treatment
Current treatment for AHF is primarily symptomatic, focusing on decongestive therapies such as intravenous diuretics and vasodilators, tailored to the patient's initial hemodynamic status . However, this approach often overlooks the underlying pathophysiological mechanisms, leading to high mortality and hospital readmission rates .
Novel Therapies and Approaches
Despite advances in chronic heart failure management, AHF remains associated with high morbidity and mortality, with no significant improvements from recent drug trials. Novel vasoactive agents and alternative models to traditional hospital admission are being explored, but robust evidence is still lacking . There is a critical need for individualized treatment plans and standardized management programs, including immediate identification and management of cardiogenic shock and the establishment of heart failure networks for close monitoring.
Special Considerations for Valvular Heart Disease
Valvular heart disease (VHD) is frequently associated with AHF, complicating the clinical presentation and management. The rapid variation in loading conditions and the presence of combined valvular lesions make it difficult to assess the severity of VHD in AHF patients. Current guidelines are not well-defined for this subset of patients, highlighting the need for more evidence-based interventions.
Conclusion
Acute heart failure is a complex and multifaceted syndrome with significant diagnostic and therapeutic challenges. While current treatments focus on symptomatic relief, there is an urgent need for more individualized and pathophysiology-targeted approaches to improve patient outcomes. Future research should aim to develop and validate new therapies and management strategies, particularly for patients with comorbid conditions like valvular heart disease.
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