الفهرس 
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Abstract
Acute heart failure consists of a varied set of clinical syndromes characterized by a sudden decrease in cardiac function and systemic hypoperfusion. The most serious manifestation of AHF is severe refractory cardiogenic shock, which carries a mortality rate in the range of 50% to 80%.
Acute decompensated heart failure (ADHF) is a syndrome due to a broad range of cardiovascular disorders. The underlying pathophysiology is heterogeneous and depends on the nature, time course and severity of the underlying cardiac disease and the presence and severity of no cardiac precipitating factors. The heterogeneity of patients with ADHF makes it difficult to develop a single pathophysiologic model. Despite this heterogeneity, there are some important themes in patients with ADHF that guide the approach to patient management. The underlying causes are heterogeneous but most patients seek medical attention because of dyspnea due to elevated left atrial and pulmonary capillary wedge pressure.
The cornerstones in making the diagnosis are the patient’s history and the clinical examination. Patients admitted with symptoms generally suggestive for heart failure and a typical history should be subjected to a 2-min bedside clinical-hemodynamic examination. Furthermore, potential conditions triggering acute cardiovascular decompositions have to be identified whenever feasible. However, to diagnose acute heart failure may be difficult as the symptoms and physical findings are non-specific and insensitive . Echocardiography is, for sure, the most valuable tool to underline the diagnosis
The immediate goal of therapy for AHF is to restore systemic perfusion to levels that will avoid the development of secondary organ failure. Initial
treatment is focused on relieving respiratory distress and correcting hypoxia.. Pharmacologic therapy is focused on relieving pulmonary congestion. Initial treatment of AHF includes vasodilators, diuretics, anticoagulants, volume management, and for ischemic heart failure, prompt interventional or surgical revascularization is the standard of care. The initial approach and basic principle of treatment for CS are to maintain ventilation, obtain euvolemia, and administer vasopressors or inotropes for the prevention or treatment of multi-organ dysfunction. Diuretics are a key of symptomatic treatment in AHF patients with signs of significant fluid overload and congestion. Vasodilators provide additional symptomatic relief to diuretics and are the second most used drugs in AHF. there is sufficient evidence to recommend using more vasodilators associated with lower doses of diuretics.
Despite aggressive treatment approaches for this challenging population, the long-term prognosis is poor and more advanced treatment options are necessary.
The use of intravenous inotropes is not indicated in most patients with ADHF except those with LV systolic dysfunction with cardiogenic shock, evidence of low cardiac output or end-organ dysfunction, hypotension or heart failure unresponsive to diuretics and parenteral vasodilators.
Mechanical circulatory support technology that can restore normal levels of cardiac output with improved systemic perfusion helps to avoid end-organ damage and can have an important impact on survival for the AHF population. Ventricular assist devices (VADs) vary from large extracorporeal systems to small devices that can be inserted percutaneously. The surgically placed VAD systems might be preferable for postcardiotomy shock because
these devices can provide uni- or biventricular support and enable an easy transition from cardiopulmonary bypass. The percutaneous VADs are designed primarily for LVAD support and are best used in patients with AHF after acute myocardial infarction, or for those with acute cardiac decompensation from other causes.
In conclusion, an array of interventional therapeutics is available in the modern era for the management of decompensated heart failure. The current use of percutaneously inserted VADs is leading to a paradigm shift in the treatment of decompensated heart failure. Supportive medical therapy, along with rapidly applied circulatory assistance, can help to avoid the development of multisystem failure and death. Early utilization of mechanical circulatory support instead of escalating doses of inotropes and vasopressors might avoid the downward spiral seen in patients with cardiogenic shock and resulting in high mortality rates. Appropriate device selection is still a complex decision process and we expect to obtain more objective data in the near future to help in the decision process, taking into account simultaneously the severity of cardiogenic shock, goals of care, patient-specific risks and technical limitations along with assessment for futility of care. Nevertheless, further large-scale studies are still needed to compare the efficacy of mechanical circulatory support and chemical agents for the management of decompensated heart failure.