Acute heart failure (AHF) represents a significant clinical and economic burden due to its impact on patients' quality of life, poor prognosis, and high healthcare costs. Despite advancements in treatment, the optimal therapeutic management of these patients, particularly those with severely reduced ejection fraction and dilated left ventricles, remains uncertain. The last European Society of Cardiology (ESC) guidelines gave a weak recommendation for using intravenous (IV) vasodilators in patients with adequate systolic blood pressure. This is derived from heterogeneous randomized controlled trials (RCTs) enrolling all-comers heart failure patients. Those studies did not specifically target conditions that from a pathophysiological perspective might derive potential positive response from vasodilators like left ventricle dilatation, significant mitral regurgitation and/or increased filling pressure. Patients with such characteristics show higher myocardial wall tension and are particularly vulnerable to afterload increases, positioning them as optimal candidates for vasodilator therapy during acute decompensation. Little evidence is available from real world cohort study on the benefit of vasodilators in this group of patients. Many of these studies used pre-defined protocol and invasive hemodynamic monitoring. On the contrary the use of echocardiographic evaluation to phenotype, infer hemodynamic parameters and assess treatment effect has become the most common adopted technique in real life.

The present prospective registry aims to investigate acute treatment management and outcomes in a focused population of patients admitted for an acute decompensation of heart failure (ADHF) with severely reduced ejection fraction and dilated left ventricle or significant functional mitral regurgitation.

Inclusion Criteria:

• Patients within 24h since admission for an ADHF defined as

  1. signs and symptoms of volume overload with necessity of iv diuretic treatment.

  2. and NT-proBNP (N-terminal pro-B-type natriuretic peptide) >1500 pg/mL or a B-type natriuretic peptide level of >500 ng/mL.

     • Admission echocardiography with evidence of a dilated left ventricle and/or at least moderate functional mitral regurgitation (FMR), reduced ejection fraction (<40%), increased LV (II/III degree diastolic dysfunction) and pulmonary pressure (sPAP ≥ 40 mmHg or MPAP ≥ 20 mmHg).

     Exclusion Criteria:

     - Cardiogenic shock at admission warranting immediate MCS / inotropic support, severe renal or hepatic impairment, recent myocardial infarction, and other terminal illnesses.

     • Use of vasopressors/inotropes or mechanical support at admission. Methods Patients will receive treatments according to their physician's discretion based on ESC guidelines. Serial evaluations of heart function will be conducted using echocardiography and lung ultrasound (LUS) at multiple time points as well as hemodynamic data, laboratory and HF medications' prescription and dosages Primary endpoint

       • 3 months incidence of need of Heart Replacement Therapies (LVAD or heart transplantation) and/or heart failure re-hospitalization and/or all-cause death.

     Secondary endpoints • In hospital and 3 months All-cause death

     • All cause and HF related hospitalizations within 3 months

     • Heart replacement therapies (LVAD or heart transplantation) within 3 months.

     • In hospital Worsening Heart Failure (WHF)

     • Need of renal replacement therapy (RRT) within 3 months

     • In-hospital length of stay (days), NT-proBNP variations, GDMT and diuretics prescription and dosages up to three months;

     Objectives:

  1. To describe the acute therapeutic management and discharge prescriptions for heart failure medications, including doses, in a selected population with ADHF.
  2. To evaluate clinical outcomes and NT-proBNP variation in relation to initial intravenous medications, particularly comparing the use versus non-use of vasodilators.
  3. To identify the incidence and timing of a significant therapeutic response through serial evaluations of LUS and echo-derived parameters, and to examine their association with the initial intravenous medications prescribed.
  4. To investigate the association between the criteria for therapeutic response and clinical outcomes in both short- and medium-term follow-up, with a focus on the relationship to the initially administered therapy.

This is a real-life, observational, prospective multicenter registry. Patients fulfilling inclusion and exclusion criteria will be consecutively enrolled in enrolling center.

Enrolled patients will be treated at each treating physician's discretion referring to the general recommendation of the last ESC guidelines on management of acute heart failure as well as local practice. General guidelines for vasodilators use will be shared among enrolling centers to increase uniformity of treatment in case of prescription of this strategy.

-After achievement of adequate decongestion, iv vasodilators infusion (if used) will be weaned and HF medications introduction/titration up to guidelines recommended doses.

Other therapeutic interventions: will be left to treating physician discretion aiming to decongest the patient.

Starting inotropes, vasopressors, mechanical cardiac support device (MCS) and use of non-invasive and/or invasive ventilation as well as continuous renal replacement therapies (CRRT) will be left to the treating physicians' discretion according to clinical course.

Inclusion Criteria:

• Patients within 24h since admission for an acute decompensation of heart failure (ADHF)* (both acute on chronic and de novo) defined as

  1. signs and symptoms of volume overload with necessity of iv diuretic treatment.
  2. and NT-proBNP (N-terminal pro-B-type natriuretic peptide) >1500 pg/mL or a B-type natriuretic peptide level of >500 ng/mL.

AND ALL THE FOLLOWING echo entry criteria at admission:

1. A dilated left ventricle (defined as a indexed LVEDD ≥ 31 mm/sm and ≥ 32 mm/sm or a indexed LVEDVol ≥ 75 ml/sm and ≥ 62 ml/sm in men and women respectively) AND/OR at least moderate functional mitral regurgitation (FMR).
2. Reduced ejection fraction (<40%)
3. Increased LV filling pressure (defined as II°-III° Diastolic dysfunction) AND increased pulmonary artery pressure (i.e. echo estimated systolic pulmonary artery pressure [sPAP] ≥ 40 mmhg and/or echo estimated mean pulmonary artery pressure [mPAP] ≥ 20 mmHg).

Exclusion Criteria:

• Patients presenting in Cardiogenic shock defined as hypotension (SBP < 90mmHg or MAP ≤ 55) AND hypoperfusion (defined as arterial lactates > 4 mmol/L)
• Estimated GFR <=20 ml/min/1.73 m2 or in chronic renal replacement therapies.
• End-stage hepatic impairment
• Use of temporary mechanical support at the moment of study inclusion or planned to use it within hours (IABP; Impella, VA ECMO)
• Ongoing treatment with vasopressors/inotropes at the moment of randomization or administration of Levosimendan within 30 days before randomization. Patients admitted for a planned cycle of Levosimendan infusion will be excluded by the present study as well.
• AHF secondary to recent onset tachy-arrhythmias
• ST tract elevated myocardial infarction (STEMI) < 30 days, myocarditis <30 days, AHF due to severe primary valve disease or clinical suspicion of an acute mechanical cause of AHF
• restrictive cardiomyopathy, constrictive pericarditis, hypertrophic obstructive cardiomyopathy, tako-tsubo syndrome
• Infective endocarditis, concomitant active septic disease as predominant cause of decompensation or admission TC>38°c.
• LVAD carriers or Heart transplant recipients
• Terminal illness other than heart failure with an expected survival <180 days

All-comers patients admitted for an ADHF with a severely reduced ejection fraction, a dilated left ventricle or significant functional mitral regurgitation (FMR) and increased left ventricle filling and pulmonary pressures as estimated by echocardiographic evaluation at admission.