ABSTRACT
Heart failure has become a global epidemic. Cardiogenic shock and decompensated heart failure constitute a large proportion of admissions to intensive care units, and rates of re-hospitalization and mortality over the subsequent year are high. Categorizing patients with heart failure with reduced ejection fraction (HFrEF), according to a hemodynamic profile based on volume status and systemic perfusion, identifies distinct clinical phenotypes with varying risk and guides therapeutic interventions. Once the hemodynamic profile is established, the mainstays of medical management for decompensated HFrEF in the intensive care unit include decongestion, inotropic support, and systemic vasodilators. The landmark PARADIGM- heart failure (HF) trial compared angiotensin receptor-neprilysin inhibitor (ARNI) therapy with sacubitril-valsartan to traditional ACE inhibition with enalapril in more than 8000 ambulatory HFrEF patients. PIONEER-HF thus established the safety and efficacy of initiating ARNI therapy among inpatients with decompensated HFrEF. Expansion of ARNI use in the population can lead to substantial improvements in patient outcomes.
