Figure 4. Classification of Patients Presenting With Acute
Decompensated HF
(eg, narrow pulse pressure,
cool extremities, hypotension)
Low perfusion at rest?
Congestion at rest?
(eg, orthopnea, elevated jugular venous pressure, pulmonary rales,
S3 gallop, edema)
NO
YES
NO
Warm and dry
Warm and wet
YES
Cold and dry
Cold and wet
Adapted from Nohria A, et al. JAMA. 2002;287:628-640.
Renal Replacement Therapy—Ultrafiltration
ÎÎUltrafiltration may be considered for patients with obvious volume
overload to alleviate congestive symptoms and fluid weight. (IIb-B)
ÎÎUltrafiltration may be considered for patients with refractory
congestion not responding to medical therapy. (IIb-C)
Parenteral Therapy in Hospitalized HF
ÎÎIf symptomatic hypotension is absent, intravenous nitroglycerin,
nitroprusside, or nesiritide may be considered as an adjuvant to
diuretic therapy for relief of dyspnea in patients admitted with acute
decompensated HF. (IIb-A)
Venous Thromboembolism Prophylaxis in Hospitalized Patients
ÎÎA patient admitted to the hospital with decompensated HF should
receive venous thromboembolism prophylaxis with an anticoagulant
medication if the risk–benefit ratio is favorable. (I-B)
Arginine Vasopressin Antagonists
ÎÎIn patients hospitalized with volume overload, including HF, who have
persistent severe hyponatremia and are at risk for or having active
cognitive symptoms despite water restriction and maximization of
GDMT, vasopressin antagonists may be considered in the short term to
improve serum sodium concentration in hypervolemic, hyponatremic
states with either a V2 receptor–selective or a nonselective
vasopressin antagonist. (IIb-B)
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