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

Inpatient Management of Congestive Heart Failure Exacerbation

Patients admitted with heart failure exacerbation should be promptly treated with intravenous loop diuretics to reduce morbidity, with the initial IV dose equaling or exceeding their chronic oral daily dose. 1, 2

Initial Assessment and Stabilization

Identify Precipitating Factors

• Acute coronary syndrome/ischemia
• Uncontrolled hypertension
• Atrial fibrillation and other arrhythmias
• Infections (particularly pulmonary and urinary tract)
• Medication or dietary non-compliance (accounts for 21-22% of exacerbations) 3, 4
• Inappropriate medication use (NSAIDs, calcium channel blockers, antiarrhythmics)
• Pulmonary embolism
• Renal failure
• Thyroid dysfunction 1

Immediate Interventions

1. Oxygen therapy for hypoxemia 1, 2

2. IV loop diuretics (furosemide, bumetanide, or torsemide) 1, 2

   • Initial IV dose should equal or exceed chronic oral daily dose
   • For patients on oral furosemide 40mg daily, start with at least 40mg IV
   • Administer as intermittent boluses or continuous infusion

3. For hypotension with hypoperfusion: Consider inotropic or vasopressor support 1

4. For respiratory distress: Consider non-invasive ventilation 1

Monitoring and Assessment

Daily Monitoring

• Fluid intake and output
• Vital signs (including standing blood pressure)
• Daily body weight (measured at same time each day)
• Clinical signs of congestion (JVP, edema, lung examination)
• Serum electrolytes, BUN, and creatinine 1, 2
• BNP or NT-proBNP levels to assess severity and response 1

Diagnostic Testing

• ECG to identify ischemia or arrhythmias
• Chest radiograph to assess pulmonary congestion
• Echocardiography to assess cardiac function if not recently performed
• Cardiac troponin to rule out acute coronary syndrome 1

Management of Volume Overload

Diuretic Strategies

1. Initial approach: IV loop diuretics (furosemide, bumetanide, torsemide) 1, 2
2. If inadequate response:
   • Increase dose of loop diuretic
   • Add second diuretic (thiazide, metolazone)
   • Switch to continuous infusion of loop diuretic 1, 2
3. For diuretic resistance:
   • Consider low-dose dopamine infusion to improve renal blood flow 1
   • Consider ultrafiltration for selected patients with refractory congestion 1

Guideline-Directed Medical Therapy (GDMT)

Continuation of Chronic Medications

• Continue pre-existing GDMT during hospitalization unless contraindicated 1
• Do not routinely discontinue GDMT for mild decreases in renal function or asymptomatic hypotension 1
• For patients with marked volume overload: Consider temporary reduction in ACE inhibitors, ARBs, or aldosterone antagonists until renal function improves 1

Initiation of New Therapies

• For patients not previously on GDMT: Initiate after clinical stability is achieved 1
• Beta-blockers: Start only after optimization of volume status and discontinuation of IV diuretics/vasodilators/inotropes 1, 5
  • Start at low dose (e.g., metoprolol succinate 12.5mg daily)
  • Use caution in patients who required inotropes during hospitalization

Management of Specific Scenarios

Cardiogenic Shock

• Invasive hemodynamic monitoring
• Inotropic support (dobutamine, milrinone)
• Consider mechanical circulatory support in selected cases 1

Atrial Fibrillation with Rapid Ventricular Response

• Rate control with beta-blockers or digoxin
• Consider anticoagulation based on stroke risk 1

Hypertensive Heart Failure

• IV vasodilators (nitroglycerin, nitroprusside)
• Continue or initiate antihypertensive therapy 1

Discharge Planning and Transitions of Care

Pre-Discharge Checklist

1. Resolution of clinical evidence of congestion
2. Optimization of oral GDMT
3. Patient education on:
   • Medication adherence
   • Daily weight monitoring
   • Dietary sodium restriction
   • Recognition of worsening symptoms
4. Plan for diuretic adjustment post-discharge
5. Schedule follow-up appointment within 7 days of discharge 1, 2

Transitional Care Plan

• Clear documentation of medication changes
• Communication with outpatient providers
• Plans for titration of GDMT to target doses
• Laboratory monitoring schedule 1

Common Pitfalls to Avoid

1. Premature discontinuation of diuretics due to small increases in creatinine (increases up to 0.3 mg/dL are acceptable during active diuresis) 2

2. Discontinuation of GDMT during hospitalization, which is associated with worse outcomes 1

3. Discharging patients with residual congestion, which increases risk of readmission 1

4. Inadequate identification and treatment of precipitating factors 3, 4, 6

5. Insufficient patient education about medication adherence and dietary restrictions 2

6. Lack of early follow-up after discharge, which should occur within 7 days 1, 2