How do you approach caring for patients admitted with decompensated CHF, but who also exhibit hypotension and do not have overt signs of hypervolemia on exam?

This is a case where you might be concerned about the patient sliding into cardiogenic shock. Remember that in the context of chronic heart failure, cardiogenic shock tends to present more insidiously because these patients are typically compensated at low or borderline low cardiac output (Abraham e...

1. Fluid in ADHF is always the wrong answer.
2. This is likely trajectory 2 or 3 in recent ADHF guidelines.
3. Rule out ischemia/sepsis.
4. Needs RHC and inotropic support.
5. Start considering advanced therapy workup.

Always attempt to stabilize the shock state first, so early vasopressor use may be the only first option if the patient is truly hypotensive - maintenance of perfusion is key.

Once the patient is stable, you can then ascertain the volume status with bedside POCUS, such as evaluation of IVC and EF (a...

Colloid… albumin. Consider a blood transfusion if hemoglobin is low. Pressors such as low-dose dobutamine may also be beneficial. Avoid diuretics as much as possible.

The INTERMACS scale has been extremely helpful to me in assessing these patients and determining what to do at 3 PM or 3 AM.

INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) Profiling Identifies Ambulatory Patients at High Risk on Medical Therapy After Hospitalizations ...