What is the general treatment for heart failure exacerbation?

General Treatment for Heart Failure Exacerbation

The general treatment for heart failure exacerbation should include intravenous diuretics as first-line therapy, with loop diuretics administered at doses equal to or exceeding the patient's chronic oral daily dose, followed by careful monitoring and adjustment of the medication regimen based on clinical response. 1, 2

Initial Management

Diuretic Therapy

• Initial approach: Administer intravenous loop diuretics (furosemide, bumetanide, or torsemide) at doses equal to or exceeding the patient's chronic oral daily dose 1
• Monitoring: Assess urine output, signs/symptoms of congestion, and titrate diuretic dose accordingly to relieve symptoms and reduce fluid overload 1
• When diuresis is inadequate, intensify the regimen using:
  1. Higher doses of loop diuretics
  2. Addition of a second diuretic (metolazone, spironolactone, or IV chlorothiazide)
  3. Continuous infusion of loop diuretics 1

Hemodynamic Support

• For patients with hypotension and hypoperfusion with elevated cardiac filling pressures, administer intravenous inotropic or vasopressor drugs (e.g., dobutamine) to maintain systemic perfusion 1, 3
• Caution: Inotropes like dobutamine and milrinone should be limited to short-term use (<48 hours) as they are associated with increased risk of arrhythmias and mortality with prolonged use 3, 4

Medication Management

Continuation of Chronic Therapies

• Continue evidence-based oral therapies in most patients, particularly:
  • ACE inhibitors or ARBs
  • Beta-blockers
  • Mineralocorticoid receptor antagonists (MRAs)
  • SGLT2 inhibitors 1, 2
• Only discontinue these medications in cases of hemodynamic instability or specific contraindications 1

Medication Initiation

• For patients not previously on guideline-directed medical therapy, initiate these medications prior to discharge once stabilized:
  • ACE inhibitors/ARBs (or consider ARNI)
  • Beta-blockers (only after optimization of volume status and discontinuation of IV diuretics, vasodilators, and inotropic agents)
  • MRAs
  • SGLT2 inhibitors 1, 2

Monitoring and Assessment

• Daily monitoring:

  • Fluid intake and output
  • Vital signs
  • Body weight (measured at same time each day)
  • Clinical signs of systemic perfusion and congestion
  • Serum electrolytes, urea nitrogen, and creatinine 1

• Consider invasive hemodynamic monitoring in patients with:

  • Respiratory distress
  • Clinical evidence of impaired perfusion
  • Uncertain intracardiac filling pressures 1

Transition to Discharge

• Transition from intravenous to oral diuretic therapy with careful attention to dosing and electrolyte monitoring 1
• Reconcile all medications at admission and discharge 1
• Provide comprehensive written discharge instructions covering:
  • Diet (sodium and fluid restriction)
  • Discharge medications with focus on adherence and uptitration
  • Activity level
  • Follow-up appointments
  • Daily weight monitoring
  • Action plan for worsening symptoms 1
• Utilize post-discharge care systems to facilitate transition to outpatient care 1

Special Considerations

Diuretic Resistance

• For patients with diuretic resistance, consider:
  • Continuous infusion of furosemide (starting at 20 mg/h, gradually increasing to maximum 160 mg/h if needed) 5, 6
  • Addition of acetazolamide as adjunctive therapy, which has shown to increase diuresis, natriuresis, and improve dyspnea 7
  • High-dose furosemide (250-4000 mg/day) may be effective in patients with significantly reduced renal function 8

Monitoring Pitfalls

• Avoid excessive diuresis leading to worsened renal function
• Monitor for electrolyte abnormalities, particularly hypokalemia and hyponatremia
• Be cautious with rapid correction of hyponatremia
• Avoid NSAIDs which can worsen renal function and fluid retention 2

Continuous vs. Bolus Diuretic Administration

• Both continuous infusion and bolus injection of furosemide can be effective, though some studies suggest continuous infusion may be superior, particularly at the beginning of hospital treatment 9, 6
• Consider continuous infusion in patients with severe heart failure or diuretic resistance 5, 6