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Inotropic agents should only be administered in acute decompensated heart failure (ADHF) refractory to vasodilators at optimal doses because they are associated with adverse outcome. In this setting a noninvasive hemodynamic monitoring system (NHMS) could be useful for optimizing treatment.Inclusion criteria: advanced chronic heart failure, ejection fraction 30% or less, admission for ADHF with systolic blood pressure 115 mmHg or less and inadequate response at 48 h of therapy. Patients were evaluated with a NHMS: with vascular systemic resistance (VSR) greater than 1500 dyne × s/cm5 we used vasodilators at increasing doses, with VSR less than 1500 and cardiac index (CI) less than 2.4 l/min per m2 inotropic agents were used.The study population consisted of 20 patients (mean age 67 ± 12 years) with ejection fraction 20 ± 7%. After 48 h of clinical-guided therapy, none of the patients achieved VSR 1500 or less, and 12 patients had a CI less than 2.4 l/min per m2. After hemodynamic-guided therapeutic optimization there was a significant reduction of dyspnea at rest (7.7 ± 1.25 versus 2.44 ± 1.33 on the 10-point Likert scale, P < 0.001) and ‘cold’ presentation (12 patients before and 1 patient after, P = 0.0004). Daily urinary volume was higher (1217 ± 369 versus 2260 ± 797 ml, P = 0.001) without renal function deterioration (creatinine 1.56 ± 0.52 versus 1.34 ± 0.61 mg/dl, P = 0.012).The nitroprusside dosing was increased after NHMS (0.13 ± 0.19 versus 0.4 ± 0.310 μg/kg per min, P = 0.044), whereas doses of inotropic agents, diuretics and beta-blockers did not change significantly.In refractory ADHF a NHMS improves significantly symptoms and renal function, with a better use of vasodilators.