What is the full 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, with the initial IV dose equaling or exceeding their chronic oral daily dose, while monitoring fluid status, electrolytes, and renal function daily. 1

Initial Assessment and Stabilization

• Oxygen therapy: Administer for hypoxemia to maintain adequate oxygenation
• Monitoring: Implement continuous monitoring of:
  • Vital signs (including orthostatic measurements)
  • Daily body weight (same time each day)
  • Fluid intake and output
  • Clinical signs of congestion and perfusion
  • Daily electrolytes, BUN, and creatinine 2, 1
• Diagnostic tests:
  • ECG to assess for arrhythmias or ischemia
  • Chest radiograph to evaluate pulmonary congestion
  • Echocardiography to assess cardiac function if not recently performed
  • BNP/NT-proBNP to confirm diagnosis and assess severity

Diuretic Management

• Initial approach: IV loop diuretics (furosemide, bumetanide, or torsemide) 1

  • Starting dose should equal or exceed patient's chronic oral daily dose
  • Can be given as bolus or continuous infusion

• For inadequate response (intensify regimen): 2

  • Increase dose of loop diuretic
  • Add second diuretic (thiazide, metolazone, or IV chlorothiazide)
  • Consider continuous infusion of loop diuretic

• Monitoring during diuresis:

  • Daily weight, I/O, electrolytes, BUN, creatinine
  • Small increases in creatinine (up to 0.3 mg/dL) are acceptable if decongestion is occurring 1
  • Target resolution of clinical congestion before discharge

Guideline-Directed Medical Therapy (GDMT)

• Continuation of pre-existing GDMT: 2, 1

  • Continue ACE inhibitors/ARBs, beta-blockers, and MRAs during hospitalization unless hemodynamically unstable or contraindicated
  • Do not routinely discontinue for mild decreases in renal function or asymptomatic hypotension

• Initiation of GDMT in treatment-naïve patients: 2

  • Start after clinical stability is achieved
  • Begin with low doses and titrate gradually
  • Beta-blockers should be initiated only after:
    • Optimization of volume status
    • Successful discontinuation of IV diuretics and inotropes
    • Patient is stable 2, 1

Management of Hemodynamic Compromise

• For hypotension with hypoperfusion and elevated filling pressures: 2

  • Consider intravenous inotropic drugs (dobutamine) to maintain systemic perfusion
  • Note: Dobutamine is indicated for short-term treatment (≤48 hours) of cardiac decompensation due to depressed contractility 3

• For severe cases:

  • Consider invasive hemodynamic monitoring to guide therapy when clinical assessment of filling pressures is uncertain 2
  • For cardiogenic shock, optimize filling pressures and consider mechanical circulatory support 4, 5

Discharge Planning and Transition of Care

• Prior to discharge, ensure: 2, 1

  • Resolution of clinical evidence of congestion
  • Optimization of oral GDMT
  • Transition from IV to oral diuretics with careful attention to dosing
  • Medication reconciliation with adjustments as appropriate

• Comprehensive discharge instructions: 2

  • Diet (sodium and fluid restrictions)
  • Discharge medications with focus on adherence
  • Activity recommendations
  • Daily weight monitoring instructions
  • Follow-up appointments (within 7-14 days)
  • Action plan for worsening symptoms

• Post-discharge systems of care: 2

  • Utilize available systems to facilitate transition to outpatient care
  • Ensure clear communication with outpatient providers

Common Pitfalls to Avoid

• Premature discontinuation of GDMT during hospitalization 1
• Discharging patients with residual congestion 1
• Failure to identify and treat precipitating factors 1
• Inadequate patient education about medication adherence and dietary restrictions 1
• Lack of early follow-up after discharge 1
• Insufficient diuretic intensification when response is inadequate 1
• Stopping diuretics prematurely due to small increases in serum creatinine 1

By following this comprehensive approach to inpatient management of heart failure exacerbation, clinicians can effectively treat acute symptoms, prevent complications, and establish a foundation for long-term management to reduce readmissions and improve outcomes.