What treatment is recommended for a patient with acute exacerbation of Heart Failure with reduced Ejection Fraction (HFrEF) presenting with hypotension, who is holding Blood Pressure (BP) medications, and experiencing Shortness of Breath (SOB)?

From the Guidelines

For a patient with acute exacerbation of heart failure with reduced ejection fraction (HFrEF), hypotension (BP 96/48), and shortness of breath (SOB), I recommend immediate treatment with intravenous loop diuretics such as furosemide 40-80 mg IV, as supported by the 2013 ACCF/AHA guideline for the management of heart failure 1. Despite the low blood pressure and holding of oral BP medications, diuresis remains the cornerstone of treatment for acute heart failure with fluid overload. The use of diuretics in this context is aimed at improving symptoms by reducing fluid retention, as stated in the guideline 1. Supplemental oxygen should be provided to maintain oxygen saturation above 92%, as hypoxemia can exacerbate symptoms and worsen outcomes. If the patient has significant respiratory distress, non-invasive positive pressure ventilation (NIPPV) like BiPAP or CPAP can be considered to reduce work of breathing and improve oxygenation. For patients with severe hypotension (systolic BP <90 mmHg) with signs of cardiogenic shock, inotropic support with dobutamine or milrinone may be necessary, as indicated in the 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults 1. These treatments work by reducing pulmonary congestion through diuresis, improving oxygenation, and potentially enhancing cardiac output with inotropes if needed. Careful monitoring of vital signs, urine output, electrolytes (especially potassium), and renal function is essential during treatment, as emphasized in the guidelines 1. Once the patient stabilizes, gradual reintroduction of guideline-directed medical therapy for HFrEF should be considered. Key considerations in the management of these patients include:

• Identifying and addressing potential precipitating factors for acute heart failure, such as acute coronary syndromes, severe hypertension, arrhythmias, infections, and renal failure 1.
• Monitoring the effect of HF treatment through careful measurement of fluid intake and output, vital signs, body weight, and clinical signs and symptoms of systemic perfusion and congestion 1.
• Adjusting the diuretic regimen as needed to relieve congestion, which may involve higher doses of loop diuretics, addition of a second diuretic, or continuous infusion of a loop diuretic 1.

From the FDA Drug Label

Furosemide may add to or potentiate the therapeutic effect of other antihypertensive drugs. Potentiation occurs with ganglionic or peripheral adrenergic blocking drugs. Furosemide may decrease arterial responsiveness to norepinephrine However, norepinephrine may still be used effectively.

For a patient admitted for acute exacerbation of HFrEF with BP 96/48, holding BP medications, and experiencing shortness of breath (SOB), caution is advised when considering treatment with furosemide.

• The patient's low blood pressure may be a concern when using furosemide, as it can potentiate the effect of other antihypertensive drugs and decrease arterial responsiveness to norepinephrine.
• However, furosemide may still be used to treat SOB in this patient, as it can help reduce fluid overload and improve respiratory symptoms.
• It is essential to monitor the patient's blood pressure and renal function closely when using furosemide in this setting, and to adjust the dosage as needed to avoid adverse effects 2.

From the Research

Treatment for Acute Exacerbation of HFrEF

• For a patient admitted with acute exacerbation of Heart Failure with reduced Ejection Fraction (HFrEF) and presenting with shortness of breath (SOB) and low blood pressure (96/48), holding BP medications, the treatment approach should focus on addressing the underlying cause of the exacerbation.
• According to 3, early administration of furosemide is associated with improved oxygenation in patients with acute heart failure, suggesting its potential benefit in this scenario.
• However, it's crucial to consider the patient's hemodynamic status, as indicated in 4, which emphasizes the importance of tailoring treatments based on blood pressure and hemodynamic status in acute heart failure management.

Considerations for Furosemide Administration

• The study 5 suggests that furosemide administration during the dry state in stable, optimally medicated outpatients with HFrEF is unfavorably associated with long-term survival, with a threshold dose of 40 mg/d.
• In contrast, 3 found that early administration of furosemide within 60 minutes of arrival at the hospital was associated with improved oxygenation in patients with acute heart failure.
• Therefore, the decision to administer furosemide should be made on a case-by-case basis, taking into account the patient's current clinical status and the potential benefits and risks.

Management of Hypotensive AHF

• For patients with hypotensive AHF, as described in 4, treatment should include emergent specialty consultation and an initial fluid bolus of 250-500 mL, followed by initiation of inotropic agents with or without vasopressors.
• Dobutamine is recommended as the inotrope of choice in these patients, with norepinephrine suggested if blood pressure support is needed.

Role of Beta-Blockers

• The management of beta-blockers in patients admitted for acute heart failure and reduced ejection fraction is discussed in 6, highlighting the importance of careful consideration in severe acute HF, including those with resolved cardiogenic shock.
• The expert consensus opinion provides a practical algorithm for the prescription and monitoring of beta-blocker therapy in critical settings, emphasizing the need for individualized care.