PA catheterization allows direct measurement of cardiac filling pressures, pulmonary arterial pressures, cardiac output, and calculation of both systemic and pulmonary vascular resistance. Widespread adoption of this technology in all critically ill patients was tempered by findings which suggested an increased cost, mortality, and length of stay [5]. Specific to the heart failure population, the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial was conducted to assess the role of PA catheter-guided therapy in hospitalized individuals with AHF. Similar to other studies, there was no suggestion that PA catheters improved mortality; it did, however, result in increased adverse events such as infection, pulmonary infarction, and bleeding [6]. It has widely been assumed that the morbidity of PA catheterization is primarily related to operator experience [7]. Despite their unproven mortality benefit, PA catheters remain a viable diagnostic tool particularly in challenging cases of AHF. The 2013 ACC/AHA guidelines for heart failure management recommend PA catheter use in cases of refractory hypotension, difficult volume status determination, renal function deterioration despite therapy, and to guide inotrope therapy titration (Class IIA (LOE C)) [2].

Management of AHF is often limited by low blood pressure and systemic hypoperfusion. Inotropic agents (e.g. dopamine, dobutamine, and milrinone) can augment contractility and chronotropy, resulting in increased stroke volume and cardiac output (Table 11.1). These goals are often accomplished with a tradeoff of increasing myocardial oxygen demand, increased heart rate, and increased risk for tachyarrhythmias. Improved hemodynamic response, however, has not always translated into improved patient survival. The Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) investigators and data from the ADHERE registry showed that these agents may actually increase mortality when compared to standard diuretic or vasodilator therapies in AHF patients [8–10]. Therefore, inotropes are best used for short periods in the ICU in situations suggestive of emerging cardiogenic shock and end-organ failure. Inotropes can also be employed as a bridge to other definitive management strategies or used for palliative care purposes.

Patients presenting with AHF and congestion should receive intravenous loop diuretics as progressive bowel wall edema may limit oral diuretic absorption and efficacy. Less well understood is the differences between adopting a continuous infusion or interval dosing diuretic strategy. The Diuretic Optimization Strategies Evaluation (DOSE) trial compared intermittent IV diuresis to a continuous infusion strategy, and found them to have a similar effect on subjective symptoms and renal function [11]. A more recent meta-analysis evaluating ten randomized control trials similarly found no difference in resulting renal function, electrolyte disturbances, length of hospitalization, or cardiac or all-cause mortality between these two approaches [12].