What Is Decompensated Heart Failure?

Decompensated heart failure, also called Acute Decompensated Heart Failure (ADHF), occurs in patients with pre-existing heart failure. It refers to a worsening of symptoms due to fluid retention (volume overload).1 These symptoms can impair the day-to-day quality of your life. For example, developing congestion in the lungs can cause wheezing, coughing, or an inability to sleep laying down at night.2 This can make it more difficult to breathe. ADHF can also cause fatigue, making you feel more tired when doing everyday activities. This can interfere with carrying out household activities or tasks at work.2

Decompensated and compensated HF

In medicine, the term decompensation refers to the deterioration of a structure or system that was previously functioning. This means the heart can no longer continue to compensate for its defects. A system that is compensated can function despite the presence of stressors or defects.

When you are in ADHF, the heart can no longer manage the amount of blood in the circulatory system leading to a buildup of pressure and fluid retention. This buildup of pressure can cause severe stress on the heart and generally requires immediate medical attention. It is a diagnosis with high rates of morbidity and mortality.1

Compensated heart failure, by contrast, describes how the heart accommodates for the deficiencies so that you may not realize there is a problem. In compensated heart failure, there are usually no symptoms or minimal ones that can be easily managed.


Chronic heart failure that has been well-managed and stable can rapidly decompensate for many reasons. A severe illness, heart attack, or not being compliant with treatment can lead to a heart failure decompensation.2 For example, changes in diet (eating more salt), increased fluid intake, and not taking medications as prescribed can be causes of decompensated heart failure. Decompensation can also occur because of any worsening of other chronic conditions. For example, high blood sugars in diabetics, COPD exacerbations, infections, or kidney problems. Underlying cardiac conditions can worsen and may also contribute to decompensation, such as a heart attack, poorly controlled blood pressure, or arrhythmias.2,4

Decompensated heart failure often presents with worsening congestion from left ventricular dysfunction. This can cause volume overload and a threat to the function of the body’s vital organs.3 Heart failure can cause the congestion of multiple organs, leading to more symptoms because those organs cannot work properly.


Symptoms of ADHF include shortness of breath, fatigue, and fluid retention. Shortness of breath, dyspnea, and difficulty breathing can get worse with ADHF.3,5 You may experience:

  • Exertional dyspnea - difficulty breathing during physical activity
  • Orthopnea - difficulty breathing while lying flat
  • Paroxysmal nocturnal dyspnea- awakening from sleep gasping for air
  • Edema- increased swelling

Other symptoms include angina (chest pain), arrhythmias, nausea, weight loss, fatigue, or a change in urinary output could also be signs of advancing heart failure. Some people also experience cognitive changes including anxiety, confusion, and memory issues.2,3,5


A diagnosis of decompensated heart failure relies on a thorough family and medical history as well as a physical exam.3,5 There is no single definitive diagnostic test. The symptoms that develop due to decompensated heart failure are an important part of the diagnostic process.1,3,5 Additionally, the distention of the jugular vein is a key clinical sign for decompensated heart failure.

Clinical details about the causes of decompensation can influence treatment choices, including medication selection. Your provider will evaluate you based on the self-reporting of symptoms, physical findings, lab tests, evaluation of ventricular function, and, if necessary, more invasive testing.2


Treating decompensated heart failure involves improving symptoms, managing underlying medical conditions, preserving renal function, and preventing further heart damage.1,2,4 It also involves hemodynamic management. This includes monitoring blood pressure, blood flow, and oxygenation levels, all of which can affect the function of the heart.3,6

The initial treatment is to manage fluid retention by using diuretics. Managing diet, fluid restrictions, and medication selection are part of the treatment protocol.3 In particular, medication selection will depend on the underlying cause and extent of damage due to ADHF. Those with systolic heart failure will be given a different medication regimen than those with diastolic HF. ADHF is a common cause of hospitalization and mortality.1

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