How do we further manage a patient with congestive heart failure (CHF) exacerbation upon admission?

Management of Congestive Heart Failure Exacerbation on Admission

For patients admitted with congestive heart failure exacerbation, prompt treatment with intravenous loop diuretics is recommended as the first-line intervention, with therapy beginning in the emergency department without delay to improve outcomes. 1

Initial Assessment and Stabilization

• Evaluate the adequacy of systemic perfusion, volume status, and identify potential precipitating factors (acute coronary syndromes, severe hypertension, arrhythmias, infections, pulmonary emboli, renal failure, medication/dietary non-compliance) 1
• Measure BNP or NT-proBNP in patients with uncertain diagnosis, interpreting results in context of all clinical data 1
• Administer oxygen therapy to relieve symptoms related to hypoxemia 1
• Consider invasive hemodynamic monitoring in patients with respiratory distress or impaired perfusion when cardiac filling pressures cannot be determined from clinical assessment 1

Diuretic Management

• For patients with significant fluid overload, initiate IV loop diuretics immediately 1
• If patients are already on oral loop diuretics, the initial IV dose should equal or exceed their chronic oral daily dose 1
• Monitor urine output, signs/symptoms of congestion, and titrate diuretic dose accordingly to relieve symptoms and reduce fluid volume excess 1
• When diuresis is inadequate to relieve congestion, intensify the diuretic regimen using one of these approaches:
  • Higher doses of loop diuretics 1
  • Addition of a second diuretic (such as metolazone, spironolactone, or IV chlorothiazide) 1
  • Continuous infusion of a loop diuretic 1
• Low-dose dopamine infusion may be considered alongside loop diuretic therapy to improve diuresis and better preserve renal function 1

Medication Management

• Continue guideline-directed medical therapy (GDMT) in patients with HFrEF experiencing exacerbation during chronic maintenance treatment, unless hemodynamic instability or contraindications exist 1
• For patients not previously on evidence-based therapies (ACE inhibitors/ARBs and beta-blockers), initiate these medications in stable patients prior to hospital discharge 1
• Consider temporary reduction or discontinuation of ACE inhibitors, ARBs, and/or aldosterone antagonists in patients with significant worsening of renal function until renal function improves 1
• Initiate beta-blocker therapy only after optimization of volume status and successful discontinuation of IV diuretics, vasodilators, and inotropic agents 1
• Start beta-blockers at a low dose and only in stable patients, using particular caution in patients who required inotropes during their hospital course 1

Monitoring During Treatment

• Monitor treatment effect with careful measurement of:
  • Fluid intake and output
  • Vital signs
  • Daily body weight (measured at the same time each day)
  • Clinical signs and symptoms of systemic perfusion and congestion 1
• Check daily serum electrolytes, urea nitrogen, and creatinine during IV diuretic use or active titration of HF medications 1
• Monitor for supine and upright hypotension, worsening renal function, and HF signs/symptoms with all medication changes 1

Management of Hemodynamic Compromise

• For patients with hypotension associated with hypoperfusion and elevated cardiac filling pressures, administer IV inotropic or vasopressor drugs to maintain systemic perfusion and preserve end-organ function while more definitive therapy is considered 1
• Dobutamine is indicated for inotropic support in the short-term treatment of patients with cardiac decompensation due to depressed contractility, but experience in controlled trials does not extend beyond 48 hours 2

Transition and Discharge Planning

• Transition from IV to oral diuretic therapy with careful attention to oral diuretic dosing and electrolyte monitoring 1
• Reconcile medications on admission and discharge, with appropriate adjustments 1
• Provide comprehensive written discharge instructions emphasizing:
  • Diet
  • Discharge medications (with focus on adherence and uptitration)
  • Activity level
  • Follow-up appointments
  • Daily weight monitoring
  • What to do if HF symptoms worsen 1
• Utilize post-discharge systems of care to facilitate transition to effective outpatient care 1

Common Pitfalls and Caveats

• Patients are often discharged after minimal weight loss, potentially remaining hemodynamically compromised despite symptomatic improvement 1
• Routine use of serial natriuretic peptide measurement or Swan-Ganz catheter has not been shown to improve outcomes 1
• Withholding beta-blockers should be considered only in patients hospitalized after recent initiation/increase in beta-blocker therapy or with marked volume overload/low cardiac output 1
• Diuretic resistance may occur, requiring combination therapy or alternative strategies 3
• Monitor for electrolyte disturbances, particularly hypokalemia and hypomagnesemia, which can increase risk of arrhythmias 3