What are the initial management steps for an inpatient with congestive heart failure (CHF) exacerbation?

Initial Management of CHF Exacerbation in Hospitalized Patients

Patients admitted with CHF exacerbation and significant fluid overload should be promptly treated with intravenous loop diuretics starting in the emergency department, with the initial IV dose equaling or exceeding their chronic oral daily dose (or 20-40 mg furosemide equivalents if diuretic-naïve), while simultaneously assessing volume status, systemic perfusion, and identifying precipitating factors. 1

Immediate Assessment (First Hour)

Upon presentation, rapidly determine five critical parameters 1:

• Adequacy of systemic perfusion - assess for hypotension, cool extremities, altered mental status, decreased urine output 1
• Volume status - evaluate jugular venous pressure, pulmonary congestion, peripheral edema, ascites 1
• Precipitating factors - identify acute coronary syndrome, severe hypertension, arrhythmias, infections, pulmonary emboli, renal failure, or medication/dietary noncompliance 1
• New-onset versus chronic exacerbation - determine if this is first presentation or decompensation of known disease 1
• Ejection fraction status - preserved versus reduced (though treatment initiation should not await this determination) 1

Essential Diagnostic Testing

Obtain immediately 1:

• Electrocardiogram and cardiac troponin - to identify acute coronary syndrome as precipitating factor 1
• Chest radiograph - assess pulmonary congestion and cardiac silhouette 1
• BNP or NT-proBNP - when contribution of HF to dyspnea is uncertain (interpret in clinical context, not as stand-alone test) 1
• Echocardiography - assess ejection fraction, chamber size, wall thickness, valve function 1

Initial Pharmacologic Management

Loop Diuretics (First-Line Therapy)

Start IV loop diuretics within 60 minutes of presentation 1, 2:

• For patients already on loop diuretics: Initial IV dose should equal or exceed chronic oral daily dose 1
• For diuretic-naïve patients: Start with 20-40 mg furosemide IV equivalents 2, 3
• Administer as intermittent boluses (continuous infusion offers no advantage per DOSE trial) 3

Monitor diuretic response at specific timepoints 2, 3:

• At 2 hours: Check spot urinary sodium (target ≥50-70 mmol/L) 2, 3
• At 6 hours: Assess urine output (target ≥100-150 mL/hour) 2, 3
• Daily: Measure weight at same time each day (target 0.5-1.5 kg loss per 24 hours) 1, 2, 3

Escalation for Inadequate Diuresis

If targets not met within first 6-24 hours, intensify regimen using 1:

1. Double the loop diuretic dose (can increase to maximum 400-600 mg furosemide daily, up to 1000 mg in severe renal dysfunction) 1, 2
2. Add second diuretic early 2, 3:
   • Acetazolamide 500 mg IV once daily - particularly effective if baseline bicarbonate ≥27 mmol/L; use only first 3 days to prevent metabolic disturbances (ADVOR trial) 2
   • Thiazide diuretic (metolazone, hydrochlorothiazide, or IV chlorothiazide) 1
   • Spironolactone 1
3. Consider continuous infusion of loop diuretic (though not superior to bolus dosing) 1

Oxygen and Respiratory Support

• Administer supplemental oxygen for hypoxemia-related symptoms 1
• Consider noninvasive positive pressure ventilation for respiratory distress 4

Management of Hypoperfusion

For patients with hypotension AND hypoperfusion AND elevated filling pressures 1:

• Administer IV inotropes or vasopressors to maintain systemic perfusion and preserve end-organ function 1
• Dobutamine is indicated for short-term inotropic support in cardiac decompensation (experience limited to 48 hours) 5

Vasodilator Therapy

In patients with severe fluid overload WITHOUT systemic hypotension 1:

• Consider adding IV vasodilators (nitroglycerin, nitroprusside, or nesiritide) when inadequate response to diuretics alone 1
• IV nitroglycerin: Start at 5 mcg/min with non-absorbing tubing, titrate by 5 mcg/min increments every 3-5 minutes 6

Ongoing Monitoring

Daily assessments must include 1:

• Fluid intake and output measurement 1
• Vital signs including supine and standing blood pressure 1
• Daily weight at consistent time 1
• Clinical signs of perfusion and congestion 1
• Daily serum electrolytes, BUN, and creatinine during IV diuretic use or medication titration 1

Guideline-Directed Medical Therapy Management

Continue Existing GDMT

In patients with reduced ejection fraction already on GDMT 1:

• Continue ACE inhibitors/ARBs and beta-blockers in absence of hemodynamic instability or contraindications 1
• Withhold or reduce beta-blockers only if: recent initiation/uptitration, marked volume overload, or marginal/low cardiac output 1
• Consider reducing/holding ACE inhibitors/ARBs/aldosterone antagonists if significant worsening renal function 1

Initiate GDMT Before Discharge

For stable patients with reduced ejection fraction not on GDMT 1:

• Initiate ACE inhibitors/ARBs and beta-blockers prior to hospital discharge 1
• Start beta-blockers at low dose only after volume optimization and discontinuation of IV diuretics, vasodilators, and inotropes 1
• Use particular caution when initiating beta-blockers in patients who required inotropes 1

Invasive Hemodynamic Monitoring

Consider pulmonary artery catheter placement when 1:

• Respiratory distress or impaired perfusion with uncertain filling pressures on clinical assessment 1
• Persistent symptoms despite empiric therapy adjustment 1
• Systolic pressure remains low or symptomatic despite initial therapy 1
• Renal function worsening with therapy 1
• Parenteral vasoactive agents required 1

Critical Pitfalls to Avoid

Common errors that worsen outcomes:

• Delaying diuretic administration - start in emergency department, not after admission 1
• Underdosing initial loop diuretic - must equal or exceed home dose 1
• Failing to monitor early diuretic response - check spot urine sodium at 2 hours and urine output at 6 hours 2, 3
• Discharging with residual congestion - associated with higher readmission rates and mortality 1, 2
• Discontinuing beta-blockers unnecessarily - associated with increased mortality 1
• Inadequate medication reconciliation - review and adjust all medications on admission and discharge 1

Discharge Planning

Before discharge, ensure 1:

• Complete resolution of congestion clinically 1, 2
• Transition to oral diuretics with careful dose adjustment and electrolyte monitoring 1
• GDMT initiated or optimized in patients with reduced ejection fraction 1
• Comprehensive written discharge instructions covering diet, medications, activity, follow-up, daily weights, and symptom management 1
• Early follow-up arranged within 2 weeks for medication uptitration 2