What is the recommended treatment for inpatient management of congestive heart failure (CHF) exacerbation?

Inpatient Treatment for CHF Exacerbation

Patients with heart failure admitted with evidence of significant fluid overload should be promptly treated with intravenous loop diuretics to improve symptoms and reduce morbidity. 1

Initial Management

Diuretic Therapy

• First-line treatment: IV loop diuretics (furosemide, bumetanide, or torsemide) 1, 2
  • Initial IV dose should equal or exceed chronic oral daily dose 1
  • Can be administered as intermittent boluses or continuous infusion 1
  • For patients on oral furosemide 40mg daily, start with at least 40mg IV 1

Monitoring During Diuresis

• Daily assessment of:
  • Fluid intake and output
  • Vital signs
  • Standing body weight (same time daily)
  • Clinical signs of congestion (JVP, edema, lung sounds)
  • Serum electrolytes, urea nitrogen, and creatinine 1

When Diuresis is Inadequate

• Intensify diuretic regimen using either:
  1. Higher doses of IV loop diuretics 1
  2. Addition of a second diuretic (thiazide, metolazone) 1
  3. Consider continuous infusion of loop diuretics for resistant cases 3

Continuation of Guideline-Directed Medical Therapy (GDMT)

• Continue GDMT during hospitalization unless hemodynamically unstable or contraindicated 1

  • ACE inhibitors/ARBs
  • Beta-blockers
  • Mineralocorticoid receptor antagonists (MRAs)

• For patients not previously on GDMT:

  • Initiate beta-blockers only after optimization of volume status and discontinuation of IV agents 1
  • Start at low dose and titrate gradually 1

Additional Interventions

For Hypoperfusion with Elevated Filling Pressures

• Consider IV inotropic therapy (dobutamine) to maintain systemic perfusion and preserve end-organ function 1, 4
  • Note: Dobutamine is indicated only for short-term treatment (≤48 hours) 4

For Respiratory Distress

• Oxygen therapy to relieve symptoms related to hypoxemia 1
• Consider continuous positive airway pressure for sleep apnea 1

For Severe Hyponatremia

• Consider vasopressin antagonists 1
• Sodium restriction (≤5g daily) 1, 5
• Fluid restriction (≤1.5L daily) in moderate to severe CHF 5

Discharge Planning

• Before discharge:
  1. Resolve clinical evidence of congestion 1
  2. Optimize oral GDMT 1
  3. Create a plan for diuretic adjustment post-discharge 1
  4. Schedule follow-up within 7-14 days of discharge 1

Common Pitfalls to Avoid

1. Premature discontinuation of diuretics due to small increases in serum creatinine (up to 0.3 mg/dL is acceptable if decongestion is occurring) 1

2. Failure to intensify diuretic therapy when response is inadequate, leading to persistent congestion at discharge (associated with higher readmission and mortality rates) 1

3. Discontinuation of GDMT during hospitalization - this is associated with worse outcomes; continue unless hemodynamically unstable 1

4. Inadequate discharge planning - ensure patients have a clear medication plan and follow-up appointment scheduled 1

5. Overlooking precipitating factors - identify and address underlying causes such as:

   • Medication non-adherence
   • Dietary indiscretion (excess sodium/fluid)
   • Uncontrolled hypertension
   • Arrhythmias (especially atrial fibrillation)
   • Infections
   • Acute coronary syndrome 1

By following this structured approach to inpatient CHF management with prompt IV diuretic therapy, careful monitoring, continuation of GDMT, and comprehensive discharge planning, you can effectively improve symptoms, reduce morbidity, and decrease the risk of rehospitalization.