What are the treatment options for decompensated heart failure (congestive heart failure)?

From the Guidelines

Decompensated heart failure should be treated with an initial intravenous dose of loop diuretic, such as furosemide 20-40mg IV, in combination with a SGLT-2 inhibitor, and guideline-directed medical therapy (GDMT) should be initiated or optimized, including ACE inhibitors/ARBs, beta-blockers, and mineralocorticoid receptor antagonists, as recommended by the most recent study 1. The treatment of decompensated heart failure involves several key components, including:

• Intravenous diuretics, such as furosemide, to reduce fluid overload and relieve symptoms of congestion 1
• Oxygen therapy to maintain saturation above 92% 1
• Vasodilators, such as nitroglycerin or nitroprusside, to reduce preload and afterload in patients with reduced ejection fraction 1
• Inotropic agents, such as dobutamine or milrinone, in cases of hypotension with poor perfusion 1
• Guideline-directed medical therapy (GDMT), including ACE inhibitors/ARBs, beta-blockers, and mineralocorticoid receptor antagonists, to reduce morbidity and mortality 1
• Daily weight monitoring, salt restriction (2-3g/day), and fluid restriction (1.5-2L/day) to manage fluid balance and prevent further decompensation 1 The underlying cause of decompensation should be identified and addressed, which may include medication non-adherence, dietary indiscretion, arrhythmias, infection, or myocardial ischemia 1. It is essential to note that the treatment approach should be individualized based on the patient's specific needs and clinical presentation, and that the most recent study 1 provides an updated algorithm for optimizing decongestion in decompensated heart failure.

From the FDA Drug Label

Dobutamine Injection, USP is indicated when parenteral therapy is necessary for inotropic support in the short-term treatment of patients with cardiac decompensation due to depressed contractility resulting either from organic heart disease or from cardiac surgical procedures Dobutamine (IV) is indicated for the short-term treatment of patients with cardiac decompensation due to depressed contractility.

• The use of dobutamine in decompensated heart failure is supported by the drug label.
• Inotropic support is necessary for the treatment of these patients. The FDA drug label for dobutamine (IV) 2 supports the use of this medication in the treatment of decompensated heart failure.

From the Research

Decompensated Heart Failure Treatment

• The treatment of acute decompensated heart failure (ADHF) often involves the use of oxygen, diuretics, and vasoactive agents such as nitroglycerin and nesiritide 3.
• Early initiation of vasodilator therapy, such as nesiritide, has been shown to improve outcomes, including shorter lengths of stay, shorter stays in the intensive care unit, and a lower mortality rate 3, 4.
• The use of inotropes, such as dobutamine and milrinone, has not been demonstrated to improve outcomes and may be deleterious 3.
• Guideline-directed medical therapy (GDMT) can be safely initiated in well-selected, treatment-naïve patients who are hemodynamically stable and clinically euvolemic after stabilization during hospitalization for heart failure 5.

Medication Initiation and Continuation

• Pre-discharge initiation of β-blocker treatment has been shown to improve clinical outcomes, including lower mortality rates and reduced rehospitalization rates, in patients with severe acute decompensated heart failure requiring inotropic therapy 6.
• Continuation of GDMT for heart failure with reduced ejection fraction (HFrEF) appears safe and well-tolerated in most hemodynamically stable patients 5.
• Hospitalization is a potential time for switching from an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker to sacubitril/valsartan therapy in eligible patients 5.

Concomitant Treatment and Renal Function

• The concomitant use of intravenous diuretics, such as furosemide, and nesiritide has been shown to improve urine output without adverse effects on renal function 7.
• The use of inotropes, such as dobutamine and milrinone, with nesiritide has been shown to tend to improve glomerular filtration rate without adverse effects on renal function or mortality 7.
• Baseline medical therapy, including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta blockers, and digoxin, does not appear to have adverse effects on renal function or mortality when used in conjunction with nesiritide 7.