What oral medications can be given for Acute Decompensated Heart Failure (ADHF) in an Emergency Room (ER) setting?

Oral Medications for Acute Decompensated Heart Failure in ER Setting

In the emergency room setting, oral diuretics are the primary oral medications for acute decompensated heart failure, with oral vasodilators being considered when blood pressure is adequate (>90 mmHg). 1

Oral Diuretic Therapy

• For patients with new-onset acute heart failure or those not receiving oral diuretics, the equivalent oral dose to the recommended IV dose would be 40 mg of oral furosemide 1, 2
• For patients already on chronic diuretic therapy, the oral dose should be at least equivalent to their previous oral dose 1, 2
• Oral loop diuretics (furosemide) remain the cornerstone of therapy for symptom relief in ADHF 1, 3
• Regular monitoring of symptoms, urine output, renal function, and electrolytes is essential during diuretic therapy 1, 4

Oral Vasodilator Options

• Oral vasodilators can be considered for symptomatic relief in ADHF with SBP >90 mmHg (without symptomatic hypotension) 1
• Nitrates (isosorbide dinitrate) can be used orally when IV administration is not necessary or as a step-down from IV therapy 1
• In patients with hypertensive ADHF, oral vasodilators should be considered to improve symptoms and reduce congestion 1

Management of Chronic Heart Failure Medications

Based on blood pressure:

• Normotension/Hypertension:

  • ACE inhibitors/ARBs: Review/increase 1
  • Beta-blockers: No change (unless contraindicated) 1
  • Mineralocorticoid receptor antagonists (MRAs): No change 1
  • Diuretics: Increase 1
  • Other vasodilators (Nitrates): Increase 1

• Hypotension (85-100 mmHg):

  • ACE inhibitors/ARBs: Reduce/stop 1
  • Beta-blockers: Reduce/stop 1
  • MRAs: No change 1
  • Diuretics: Reduce 1
  • Other vasodilators: Reduce/stop 1

• Severe Hypotension (<85 mmHg):

  • ACE inhibitors/ARBs: Stop 1
  • Beta-blockers: Stop 1
  • MRAs: Stop 1
  • Diuretics: Stop 1
  • Other vasodilators: Stop 1

Special Considerations

• In patients with ADHF and atrial fibrillation, beta-blockers are considered the preferred first-line treatment to control ventricular rate 1
• Oral beta-blockers should be used cautiously if the patient is hypotensive or showing signs of low cardiac output 1, 5, 6
• Combination of loop diuretic with either thiazide-type diuretic or spironolactone may be considered in patients with resistant fluid overload, but requires careful monitoring 1, 7

Important Caveats and Pitfalls

• Routine use of oral opioids in ADHF patients is not recommended as they may be associated with increased rates of mechanical ventilation, ICU admission, and death 1
• High doses of diuretics may lead to hypovolemia, hyponatremia, and increase the likelihood of hypotension when initiating ACE inhibitors or ARBs 2, 7
• Adding metolazone to loop diuretics has been associated with hypokalemia, hyponatremia, worsening renal function, and increased mortality; therefore, uptitration of loop diuretics may be preferred over early addition of thiazide diuretics 7
• Patients with hypotension (SBP <90 mmHg), severe hyponatremia, or acidosis are unlikely to respond well to diuretic treatment alone and may require additional interventions 2, 8

Monitoring Parameters

• Regular assessment of symptoms, vital signs, and fluid status 1, 4
• Monitoring of renal function and electrolytes (particularly potassium and sodium) 1, 4
• Assessment of urine output to evaluate diuretic response 2, 9
• Continuous monitoring of blood pressure during vasodilator therapy 1