What is the initial management for patients hospitalized with heart failure?

Initial Management for Patients Hospitalized with Heart Failure

Patients hospitalized with heart failure should be immediately treated with intravenous loop diuretics to reduce fluid overload, monitored in an appropriate setting based on clinical severity, and assessed for precipitating factors, with continuation of guideline-directed medical therapy unless contraindicated by hemodynamic instability. 1

Initial Assessment and Triage

Clinical Evaluation

• Assess adequacy of systemic perfusion, volume status, and identify precipitating factors 1
• Evaluate respiratory status: respiratory rate, oxygen saturation, work of breathing
• Check vital signs: blood pressure, heart rate, respiratory rate
• Perform targeted physical examination for signs of congestion (jugular venous distention, pulmonary rales, peripheral edema)

Risk Stratification and Triage

• High-risk patients requiring ICU/CCU admission 1:

  • Respiratory rate >25 breaths/min
  • Oxygen saturation <90% despite supplemental oxygen
  • Use of accessory muscles for breathing
  • Systolic BP <90 mmHg
  • Signs of hypoperfusion (oliguria, cold extremities, altered mental status, lactate >2 mmol/L)
  • Need for intubation

• Intermediate-risk patients: admit to telemetry or cardiac ward

• Low-risk patients: consider observation unit (<24 hours) 1

Immediate Management

Oxygen and Respiratory Support

• Administer oxygen therapy for patients with SpO₂ <90% 1, 2
• Consider non-invasive ventilation for patients with respiratory distress 1

Diuretic Therapy

• Administer intravenous loop diuretics promptly for patients with fluid overload 1
• Initial IV dose should equal or exceed chronic oral daily dose 1
• For diuretic-naïve patients, start with furosemide 20-40 mg IV
• For patients on chronic diuretics, use higher doses 1

Hemodynamic Management

• For patients with hypotension and hypoperfusion, consider intravenous inotropic or vasopressor drugs 1
• For patients with adequate blood pressure, consider vasodilators (IV nitroglycerin) as adjunctive therapy 1

Identifying and Managing Precipitating Factors

Promptly identify and address common precipitating factors 1:

• Acute coronary syndromes: Perform ECG and cardiac troponin testing
• Severe hypertension: Gradual blood pressure control
• Arrhythmias: Rate or rhythm control as appropriate
• Infections: Appropriate antibiotics
• Medication or dietary non-compliance: Patient education
• Pulmonary embolism: Anticoagulation if confirmed
• Renal failure: Adjust medications, consider nephrology consultation

Monitoring During Hospitalization

• Daily weight and accurate fluid balance chart 1
• Continuous monitoring of vital signs and oxygen saturation
• Daily measurement of renal function and electrolytes 1
• Assess for signs of improving or worsening congestion

Medication Management

Continue or Initiate Evidence-Based Therapies

• Continue guideline-directed medical therapy (GDMT) in patients with heart failure with reduced ejection fraction (HFrEF) unless hemodynamically unstable 1
• For patients with low blood pressure but no signs of hypoperfusion, GDMT can typically be continued 1
• For patients with cardiogenic shock or hypoperfusion, temporarily hold or reduce beta-blockers and/or ACE inhibitors/ARBs 1

Medication Reconciliation

• Reconcile medications on admission and discharge 1
• Adjust doses based on clinical response and laboratory values

Pre-Discharge Planning

• Ensure hemodynamic stability and euvolemia 1
• Establish patients on evidence-based oral medications 1
• Confirm stable renal function for at least 24 hours before discharge 1
• Consider measuring natriuretic peptides to guide discharge planning 1
• Provide tailored education and advice about self-care 1

Post-Discharge Follow-up

• Schedule follow-up with primary care within 1 week of discharge 1
• Arrange cardiology follow-up within 2 weeks of discharge 1
• Enroll patients in a heart failure disease management program 1

Special Considerations

Pitfalls to Avoid

• Delaying diuretic therapy in congested patients
• Discontinuing all GDMT in patients with mild-moderate hypotension without signs of hypoperfusion
• Inadequate monitoring of electrolytes and renal function during diuresis
• Discharging patients before achieving euvolemia
• Failing to identify and address precipitating factors

By following this structured approach to the initial management of patients hospitalized with heart failure, clinicians can effectively stabilize patients, relieve congestion, maintain or optimize evidence-based therapies, and prepare for successful transition to outpatient care.