Strategies for Assessment of Fluid Overload in Acute Decompensated Heart Failure

Inclusion criteria: Hospitalization for decompensated heart failure is defined as an event that meets all ofthe following criteria:

1. The patient is admitted to the hospital with a primary diagnosis of HF (previous echomandatory)
2. The patient's length-of-stay in hospital extends for at least 24 hours
3. The patient exhibits documented new or worsening symptoms due to HF on presentation,including at least ONE of the following:

• Dyspnea (dyspnea with exertion, dyspnea at rest, orthopnea, paroxysmal nocturnaldyspnea)
• Decreased exercise tolerance
• Fatigue
• Other symptoms of worsened end-organ perfusion or volume overload (as determinedby the medical judgement of the investigator)

4. The patient has objective evidence of new or worsening HF, consisting of at least twophysical examination findings OR one physical examination finding and at least ONElaboratory criterion, including:
5. Physical examination findings considered to be due to heart failure, includingnew or worsened:

• Peripheral edema
• Increasing abdominal distention or ascites (in the absence of primaryhepatic disease)
• Pulmonary rales/crackles/crepitations
• Increased jugular venous pressure and/or hepatojugular reflux
• S3 gallop
• Clinically significant or rapid weight gain thought to be related to fluidretention

2. Laboratory evidence of new or worsening HF, if obtained within 24 hours ofpresentation, including:

• Increased B-type natriuretic peptide (BNP)/ N-terminal pro-BNP (NT-proBNP)concentrations consistent with decompensation of heart failure (such as BNP > 500 pg/mL or NT-proBNP > 2,000 pg/mL). In patients with chronicallyelevated natriuretic peptides, a significant increase should be noted abovebaseline.
• Radiological evidence of pulmonary congestion
• Non-invasive diagnostic evidence of clinically significant elevated left- orright-sided ventricular filling pressure or low cardiac output. For example,echocardiographic criteria could include: E/e' > 15 or D-dominant pulmonaryvenous inflow pattern.
• Invasive diagnostic evidence with right heart catheterization showing apulmonary capillary wedge pressure (pulmonary artery occlusion pressure) ≥ 18 mmHg, central venous pressure ≥ 12 mmHg, or a cardiac index < 2.2L/min/m2

5. The patient receives initiation or intensification of treatment specifically for HF,including at least one of the following:

• Augmentation in oral diuretic therapy
• Intravenous diuretic or vasoactive agent (e.g., inotrope, vasopressor, orvasodilator)
• Mechanical or surgical intervention, including:
• Mechanical circulatory support (e.g. intra-aortic balloon pump, ventricularassist device, extracorporeal membrane oxygenation, total artificial heart)
• Mechanical fluid removal (e.g., ultrafiltration, hemofiltration, dialysis)

Exclusion Criteria:

• Acute coronary syndrome, cardiogenic chock