Decompensated Heart Failure Fluid overload Organ hypoperfusion (low cardiac output) Maximize afterload reduction with Symptomatic IV Boluses of Loop Diuretic ACE inhibitors, hydralazine pulmonary congestion Addition of Metolazone Low /Normal Elevated SVR SVR Continuous Iv Infusion of Venodilator Loop Diuretic and/or Low-Dose Dopamine Dobutamine Nitroprusside or Milrinone Hemodialysis General approach to the treatment of patients hospitalized with decompensated heart failure