What are the guidelines for managing heart failure with inadequate decongestion (decompensated heart failure)?

From the Guidelines

Managing heart failure with inadequate decongestion requires a comprehensive approach that prioritizes guideline-directed medical therapy (GDMT) and judicious use of diuretics, as recommended by the most recent guidelines 1.

Key Principles

• The initial management involves increasing the dose of loop diuretics, such as furosemide (40-80 mg IV twice daily), bumetanide (1-2 mg IV twice daily), or torsemide (20-40 mg IV twice daily) 2, 3.
• If the response is inadequate after 24-48 hours, consider adding a thiazide diuretic, such as metolazone (2.5-10 mg once daily) or chlorothiazide (500-1000 mg IV), to achieve sequential nephron blockade 1, 2.
• For persistent congestion, consider continuous IV furosemide infusion (5-10 mg/hour) or ultrafiltration in diuretic-resistant cases 2, 3.
• Implement sodium and fluid restriction (1.5-2 L/day) and maintain neurohormonal blockade with ACE inhibitors/ARBs and beta-blockers unless contraindicated 4, 5.

Monitoring and Adjustments

• Monitor daily weights, fluid intake/output, electrolytes (especially potassium and sodium), and renal function closely 2, 3.
• Adjust the diuretic dose and duration according to the patient's symptoms and clinical status 2, 3.
• Consider the use of SGLT-2 inhibitors as part of the GDMT to achieve sustained decongestion and prevent congestion development in the long run 4, 5.

Prioritizing GDMT

• The effort should be focused on implementing and fast up-titration of neurohormonal blockade (together with SGLT-2 inhibitors) once the accumulated volume is not a major clinical problem 5.
• Use the lowest possible dose of diuretics to facilitate up-titration of GDMT and mitigate the risk of diuretic-related complications 5.

From the FDA Drug Label

Dobutamine Injection, USP is indicated when parenteral therapy is necessary for inotropic support in the short-term treatment of patients with cardiac decompensation due to depressed contractility resulting either from organic heart disease or from cardiac surgical procedures The guidelines for managing heart failure with inadequate decongestion (decompensated heart failure) include the use of inotropic support with dobutamine for short-term treatment in patients with cardiac decompensation due to depressed contractility 6.

• Key points: + Dobutamine is indicated for short-term treatment of cardiac decompensation + It is used for inotropic support in patients with depressed contractility + The treatment is limited to a short duration, as experience with intravenous dobutamine does not extend beyond 48 hours of repeated boluses and/or continuous infusions.

From the Research

Guidelines for Managing Heart Failure with Inadequate Decongestion

The management of heart failure with inadequate decongestion, also known as decompensated heart failure, involves several therapeutic strategies to relieve congestion and improve patient outcomes. The following guidelines are based on current evidence:

• Initial Approach: An evidence-based initial approach to congestion management involves high-dose i.v. diuretics, such as loop diuretics, with the addition of vasodilators for dyspnea relief if blood pressure allows 7.
• Diuretic Therapy: Loop diuretics are the preferred diuretic and have been given a class I recommendation by clinical guidelines for the relief of congestion symptoms 8. The door to diuretic time should not exceed 60 min, and the starting IV dose is 20-40 mg furosemide equivalents in loop diuretic naïve patients or double the preexisting oral home dose to be administered via IV 9.
• Monitoring Response: Monitoring responses within the first hours of diuretic therapy is key. After 2 h, spot urinary sodium should be ≥50-70 mmol/L, and after 6 h, the urine output should be ≥100-150 mL/hour. If these target measures are not reached, the guidelines recommend doubling the original dose to a maximum of 400-600 mg furosemide per day 9.
• Combination Diuretic Therapy: Emerging evidence supports the concept of early combination diuretic therapy, by adding either acetazolamide or hydrochlorothiazide to loop diuretics 9, 10. Acetazolamide is particularly useful in the presence of a baseline bicarbonate level of ≥27 mmol/L and remains effective in the presence of preexisting/worsening renal dysfunction.
• Ultrafiltration: If diuretic strategies are unsuccessful, ultrafiltration may be considered. However, ultrafiltration should be used with caution in the setting of worsening renal function 7.
• Patient Discharge: Patients should not leave the hospital when they are still congested and/or before optimized long-term guideline-directed medical therapy has been initiated. Special attention should be paid to AHF patients during the vulnerable post-discharge period, with an early follow-up visit focusing on up-titrate treatments of recommended doses within 2 weeks 9.

Diuretic Resistance

Diuretic resistance is a major challenge to decongestion therapy for patients with heart failure and is associated with a poor clinical prognosis. Different therapeutic strategies can be adopted to overcome diuretic resistance, including combined diuretic therapy with thiazide diuretics and/or aldosterone antagonists 11, 10. Low or "non-diuretic" doses of aldosterone antagonists have been demonstrated to confer a survival benefit in patients with heart failure and reduced ejection fraction 11.