What are the treatment options for acute heart failure in an outpatient setting?

From the Guidelines

Outpatient treatment of acute heart failure should focus on managing symptoms, preventing hospitalization, and addressing the underlying cause, with cornerstone medications including diuretics, ACE inhibitors, and beta-blockers, as recommended by the most recent guidelines 1. The treatment approach should prioritize reducing fluid overload, improving cardiac remodeling, and enhancing cardiac function.

• Diuretics like furosemide (20-80mg daily or twice daily) are essential to reduce fluid overload by increasing urine output.
• ACE inhibitors such as lisinopril (2.5-40mg daily) or ARBs like losartan (25-100mg daily) are crucial to reduce afterload and improve cardiac remodeling, as supported by the European Society of Cardiology guidelines 1.
• Beta-blockers including metoprolol succinate (12.5-200mg daily) or carvedilol (3.125-25mg twice daily) should be initiated at low doses and gradually titrated up to improve cardiac function. For patients with reduced ejection fraction, adding an SGLT2 inhibitor like empagliflozin (10mg daily) or dapagliflozin (10mg daily) reduces hospitalizations and mortality, as shown in recent studies 1. Mineralocorticoid receptor antagonists such as spironolactone (25-50mg daily) may be added for additional benefit. Patients should restrict sodium intake to 2-3g daily, limit fluid intake to 1.5-2L daily, monitor daily weights, and follow up within 7-14 days of any medication changes. Regular monitoring of renal function, electrolytes, and blood pressure is crucial, as these medications can cause hypotension, hyperkalemia, or worsening renal function, highlighting the importance of careful patient management 1. Patients should be educated to seek immediate care if experiencing increased shortness of breath, significant weight gain, or worsening edema.

From the FDA Drug Label

The recommended starting dose of metoprolol succinate extended-release tablets is 25 mg once daily for two weeks in patients with NYHA Class II heart failure and 12. 5 mg once daily in patients with more severe heart failure. Dosage must be individualized and closely monitored during up-titration. The dose should then be doubled every two weeks to the highest dosage level tolerated by the patient or up to 200 mg of metoprolol succinate extended-release tablets If transient worsening of heart failure occurs, it may be treated with increased doses of diuretics, and it may also be necessary to lower the dose of metoprolol succinate extended-release tablets or temporarily discontinue it.

Acute Heart Failure Treatment Outpatient

• The treatment of acute heart failure with metoprolol succinate extended-release tablets should be individualized and closely monitored.
• Starting dose: 25 mg once daily for two weeks in patients with NYHA Class II heart failure and 12.5 mg once daily in patients with more severe heart failure.
• Dose titration: The dose should then be doubled every two weeks to the highest dosage level tolerated by the patient or up to 200 mg of metoprolol succinate extended-release tablets.
• Monitoring: Patients should be closely monitored for signs of worsening heart failure, and the dose of metoprolol succinate extended-release tablets should be adjusted accordingly 2.
• Lisinopril: can be used in the treatment of heart failure, the combination of lisinopril, digitalis and diuretics reduced the following signs and symptoms of heart failure: edema, rales, paroxysmal nocturnal dyspnea and jugular venous distention 3.

From the Research

Acute Heart Failure Treatment in Outpatient Settings

• Acute heart failure (AHF) is a common cause of unplanned hospital admissions, especially in patients over 65 years old, and is associated with high morbidity, mortality, and healthcare costs 4.
• The diagnosis of AHF is based on signs and symptoms, laboratory tests, and non-invasive tests, and therapeutic interventions mainly consist of intravenous diuretics and/or vasodilators, tailored to the initial hemodynamic status 4.
• Outpatient treatment of heart failure (HF) has been studied, with findings suggesting that care patterns for HF in the outpatient setting vary widely, and the use of guideline-recommended therapies by practices is not uniform 5.
• A study comparing HF patients treated in outpatient versus inpatient settings found that outpatients had a more frequent history of HF hospitalization and received more frequent beta-blockers and/or ACEi/angiotensin receptor blockers up-titrated to target doses 6.
• Diuretics play a crucial role in the management of HF, and the choice of diuretic is guided by patient clinical situations and co-morbidities, with azosemide and torasemide showing significant reductions in brain natriuretic peptide level and edema 7.
• Early management of AHF in the emergency department (ED) is critical, and clinical trials are needed to improve the evidence base and drive optimal initial therapy for AHF, with a focus on risk-stratification and predictive instruments to identify patients safe for ED discharge 8.

Treatment Options

• Intravenous diuretics and/or vasodilators are commonly used in the treatment of AHF, with the goal of reducing peripheral and/or pulmonary congestion and improving cardiac output 4.
• Beta-blockers and angiotensin-converting enzyme inhibitors (ACEi) are also used in the treatment of HF, with outpatients receiving these therapies more frequently than inpatients 6.
• Diuretics such as azosemide and torasemide have shown promise in reducing brain natriuretic peptide level and edema, and may be considered in the treatment of HF 7.

Future Directions

• Further research is needed to improve the evidence base for AHF treatment in outpatient settings, with a focus on risk-stratification and predictive instruments to identify patients safe for ED discharge 8.
• Clinical trials should be conducted in the ED to evaluate the effectiveness of different treatment strategies for AHF, including phenotype-driven therapy and early discharge 8.