What medications are used to manage acute congestive heart failure (CHF) exacerbation?

Management of Acute Congestive Heart Failure Exacerbation

Intravenous loop diuretics are the first-line treatment for acute CHF exacerbation, with furosemide 20-40 mg IV as the initial recommended dose to rapidly reduce fluid overload and relieve congestion. 1

Initial Pharmacological Management

First-Line Therapy

• IV Loop Diuretics:
  • Furosemide 40 mg IV bolus (or equivalent to oral home dose if on chronic therapy) 2, 1
  • Alternative loop diuretics: bumetanide (0.5-1.0 mg IV) or torsemide (10-20 mg IV) 1
  • For patients already on chronic oral diuretic therapy, the initial IV dose should be at least equivalent to their oral dose 2

Additional Therapies Based on Clinical Presentation

• Oxygen therapy/ventilatory support:

  • Non-invasive ventilation (NIV) should be started promptly in patients with acute pulmonary edema showing respiratory distress 2
  • CPAP is feasible in pre-hospital settings; PS-PEEP preferred for patients with acidosis/hypercapnia 2

• Vasodilators (for patients with SBP >110 mmHg):

  • IV nitrates for patients with normal to high blood pressure 2
  • Avoid in patients with SBP <110 mmHg 2

Monitoring and Dose Adjustment

• Daily monitoring:

  • Weight measurements
  • Fluid intake/output tracking
  • Vital signs
  • Electrolytes, BUN, and creatinine 1

• For inadequate diuretic response:

  • Increase loop diuretic dose
  • Consider combination therapy with thiazide diuretic (e.g., metolazone or hydrochlorothiazide)
  • Switch to continuous infusion of loop diuretic 2, 1

Management of Specific Clinical Scenarios

Cardiogenic Shock

• Defined as hypotension (SBP <90 mmHg) despite adequate filling status with signs of hypoperfusion 2
• Management:
  • Fluid challenge (>200 mL over 15-30 min) if no overt fluid overload 2
  • Dobutamine may be used to increase cardiac output 2, 3
  • Vasopressors (preferably norepinephrine over dopamine) only if strictly needed to maintain systolic BP with persistent hypoperfusion 2

Diuretic Resistance

• Consider sequential nephron blockade:
  • Add thiazide diuretic to loop diuretic
  • Consider acetazolamide to inhibit proximal tubule sodium reabsorption 2
  • Administer loop diuretic twice daily or on empty stomach 2
  • Consider short-term IV infusion of loop diuretic 2

Management of Chronic Heart Failure Medications During Acute Exacerbation

• ACE inhibitors/ARBs:

  • Continue unless patient is hemodynamically unstable or has significant renal dysfunction 1
  • Consider dose reduction if symptomatic hypotension develops 2

• Beta-blockers:

  • Continue in stable patients
  • Consider dose reduction (halve dose) if increasing congestion or marked fatigue 2, 1
  • Rarely necessary to stop completely 2

• Mineralocorticoid receptor antagonists (MRAs):

  • Continue unless contraindicated (significant hyperkalemia or renal dysfunction) 2, 1

Common Pitfalls and Cautions

• Avoid routine use of opioids in AHF patients as they may be associated with higher rates of mechanical ventilation, ICU admission, and death 2

• Avoid vasopressors and sympathomimetics except in cardiogenic shock; they should be reserved for patients with persistent signs of hypoperfusion despite adequate filling status 2

• Avoid excessive diuresis which can lead to hypotension, worsening renal function, and electrolyte abnormalities 1

• Monitor for electrolyte abnormalities:

  • Hypokalemia/hypomagnesemia: increase ACE inhibitor/ARB dose, add MRA, consider supplements 2
  • Hyperkalemia: reduce or stop MRA, monitor closely 2

• Avoid premature discontinuation of chronic HF medications such as ACE inhibitors/ARBs and beta-blockers, as this can worsen long-term outcomes 1

Transition to Oral Therapy and Discharge Planning

• Transition from IV to oral diuretics with careful monitoring
• Optimize guideline-directed medical therapy before discharge
• Provide comprehensive discharge instructions including medication regimen, daily weight monitoring, dietary sodium restriction, and follow-up appointments 1

By following this algorithm for managing acute CHF exacerbation, clinicians can effectively reduce congestion, improve symptoms, and optimize outcomes while minimizing adverse effects.