What are the management strategies for congestive heart failure (CHF) exacerbation?

Management of Congestive Heart Failure Exacerbation

For patients with CHF exacerbation, diuretic therapy is the cornerstone of treatment, with initial intravenous doses equal to or exceeding the chronic oral daily dose, along with careful monitoring of fluid status and electrolytes. 1

Initial Assessment and Management

• Perform careful measurement of fluid intake and output, vital signs, daily body weight, and clinical signs of systemic perfusion and congestion 1
• Monitor daily serum electrolytes, urea nitrogen, and creatinine during IV diuretic use or active titration of heart failure medications 1
• Administer supplemental oxygen for patients with hypoxemia 1
• Consider non-invasive ventilation (CPAP or BiPAP) for patients with persistent hypoxia and tachypnea despite oxygen therapy, as it improves cardiac hemodynamics, symptoms, and oxygenation 1, 2, 3

Diuretic Management

• Start with IV loop diuretics at doses equal to or exceeding the patient's chronic oral daily dose 1
• When diuresis is inadequate to relieve congestion, intensify the diuretic regimen using one of the following approaches: 1
  • Higher doses of loop diuretics
  • Addition of a second diuretic (metolazone, spironolactone, or IV chlorothiazide)
  • Continuous infusion of a loop diuretic

Hemodynamic Support

• 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 performance 1
• Consider dobutamine as the preferred inotropic agent for patients with low cardiac output and signs of hypoperfusion despite adequate filling 4, 5
• Caution: Long-term use of infused positive inotropic drugs is not recommended except as palliation for end-stage disease 1, 5

Invasive Monitoring

• Consider invasive hemodynamic monitoring for patients in respiratory distress or with clinical evidence of impaired perfusion when the adequacy of intracardiac filling pressures cannot be determined from clinical assessment 1

Medication Management During Hospitalization

• Reconcile medications on admission and discharge 1
• For patients with reduced ejection fraction on chronic maintenance treatment with ACE inhibitors/ARBs and beta-blockers, continue these therapies in the absence of hemodynamic instability or contraindications 1
• For patients not previously on these therapies, initiate ACE inhibitors/ARBs and beta-blockers in stable patients prior to hospital discharge 1
• Initiate beta-blocker therapy only after optimization of volume status and successful discontinuation of IV diuretics, vasodilators, and inotropic agents 1

Transition from IV to Oral Therapy

• Carefully transition from IV to oral diuretic therapy with attention to oral diuretic dosing and monitoring of electrolytes 1
• Monitor for supine and upright hypotension, worsening renal function, and heart failure signs/symptoms with all medication changes 1

For Heart Failure with Preserved Ejection Fraction (HFpEF)

• Use diuretics judiciously to reduce congestion and improve symptoms 1
• Consider SGLT2 inhibitors as disease-modifying therapy based on recent positive clinical trials 1
• Consider mineralocorticoid receptor antagonists (MRAs) for symptom management 1

Discharge Planning and Follow-up

• Provide comprehensive written discharge instructions with emphasis on: 1
  • Diet
  • Discharge medications, with focus on adherence and uptitration to recommended doses
  • Activity level
  • Follow-up appointments
  • Daily weight monitoring
  • Instructions on what to do if heart failure symptoms worsen
• Utilize post-discharge systems of care to facilitate transition to effective outpatient care 1
• Enroll patients in multidisciplinary heart failure management programs to reduce the risk of hospitalization and improve survival 1, 4

Common Pitfalls to Avoid

• Avoid routine use of calcium channel blockers in heart failure patients with reduced ejection fraction 1, 4
• Avoid NSAIDs as they can cause sodium and water retention and blunt the effects of diuretics 4
• Avoid long-term use of infused positive inotropic drugs except as palliation for end-stage disease 1, 5
• Monitor closely for complications of non-invasive ventilation including facial skin damage, gastric distension, and conjunctivitis 3, 6