Acute heart failure syndromes: assessment and reconstructing the heart

Heart failure is an international health problem, the magnitude of which is expected to continue to grow. It can be broadly divided into chronic (and relatively stable) ambulatory heart failure patients and patients hospitalized for worsening heart failure, also known as acute heart failure syndromes (AHFS). In contrast to the treatment of stable ambulatory HF patients, which has been revolutionized by evidence-based therapies with a survival benefit, the early management of patients hospitalized for AHFS has changed little over the past several decades and the postdischarge event rate (mortality and rehospitalization) within 60-90 days may be as high as 45%. Although heart failure patients frequently experience rapid and dramatic improvements in signs and symptoms of congestion in response to standard therapy alone, the early postdischarge event rate remains paradoxically elevated. Thus, even though admission for AHFS may be characterized by cardiac injury ('destruction'), hospitalization represents a rare opportunity for assessment and evaluation, as well as initiation of targeted therapies aimed at 'reconstructing' the heart. This concept is clinically relevant since many patients may be discharged home without addressing potentially reversible underlying pathophysiologic processes including, but not limited to, viable but dysfunctional myocardium and cardiac dyssynchrony.