A 62-year-old woman with acute decompensated heart failure (ADHF) presents with pulmonary oedema, elevated JVP, and a BNP of 850 pg/mL. Regarding acute management of ADHF, all of the following statements are correct EXCEPT:

Explanation

## Acute Decompensated Heart Failure: Management Principles **Key Point:** Inotropes are NOT first-line agents in ADHF and should be reserved for cardiogenic shock or hypotension refractory to other measures. Early and indiscriminate use of inotropes increases mortality risk. ### First-Line Approach to ADHF ```mermaid flowchart TD A[Acute Decompensated HF<br/>Pulmonary oedema + elevated JVP]:::outcome --> B{Haemodynamic status?}:::decision B -->|Euvolemic or congested<br/>SBP > 90| C[Loop diuretics IV]:::action B -->|Hypotensive<br/>SBP < 90| D[Vasopressor support]:::urgent C --> E{Symptom relief?}:::decision E -->|Yes| F[Continue diuretics<br/>+ vasodilators if SBP permits]:::action E -->|No| G[Add vasodilator<br/>or consider inotrope]:::action D --> H[Inotrope + vasopressor<br/>for cardiogenic shock]:::urgent C --> I[Oxygen/NIV if<br/>SpO2 < 90%]:::action ``` ### Role of Inotropes in ADHF | Scenario | Inotrope Use | Evidence | |---|---|---| | Acute pulmonary oedema, SBP > 90 mmHg | **NOT indicated** | Increases mortality; no symptom benefit over diuretics + vasodilators | | Cardiogenic shock (SBP < 90 + end-organ hypoperfusion) | **Indicated** | Bridge to mechanical support or recovery | | Low cardiac output + hypotension refractory to fluids | **Consider** | Dobutamine, milrinone as temporizing measure | | Acute MI with HF + hypotension | **Indicated** | Short-term use; aim for revascularization | **High-Yield:** The OPTIMIZE-HF and ESCAPE trials demonstrated that routine inotrope use in ADHF worsens outcomes. Inotropes increase heart rate, myocardial oxygen demand, and arrhythmia risk. Reserve them for shock states only. ### Mnemonic for ADHF Management Priorities **LOAD:** - **L** — Loop diuretics (first-line for congestion) - **O** — Oxygen / NIV (if hypoxic or respiratory distress) - **A** — ACE-I / Vasodilators (afterload reduction) - **D** — Dobutamine / inotropes (only if shock or severe hypotension) **Clinical Pearl:** In euvolemic or hypertensive ADHF, aggressive diuresis + vasodilation (nitroprusside, nitroglycerin) often resolves pulmonary oedema without inotropes. Inotropes should be a last resort, not a reflex first-line choice. **Warning:** Do not confuse "low cardiac output" with "cardiogenic shock." Low cardiac output alone (without hypotension or end-organ hypoperfusion) does not mandate inotropes. Many patients improve with diuretics and vasodilators alone.