What is the treatment for reduced ejection fraction congestive heart failure (CHF) exacerbation in the inpatient setting?

Treatment of Reduced Ejection Fraction Heart Failure Exacerbation in the Inpatient Setting

Initiate intravenous loop diuretics immediately at a dose equal to or exceeding the patient's chronic oral daily dose, continue guideline-directed medical therapy (ACE inhibitors/ARBs and beta-blockers) unless hemodynamically unstable, and initiate SGLT2 inhibitors before discharge in all stable patients. 1

Immediate Management: Diuretic Therapy

Initial Diuretic Dosing

• Start IV loop diuretics at a dose equal to or greater than the patient's chronic oral daily dose to achieve adequate decongestion 1
• Monitor urine output and signs of congestion serially, titrating the diuretic dose upward as needed to relieve symptoms and reduce extracellular fluid volume 1
• Measure daily serum electrolytes, blood urea nitrogen, and creatinine during active IV diuretic use 1

Escalation Strategies for Inadequate Diuresis

When congestion persists despite initial therapy, intensify the diuretic regimen using one of three approaches 1:

• Increase loop diuretic doses (higher bolus doses or more frequent administration)
• Add a second diuretic such as metolazone, spironolactone, or IV chlorothiazide
• Switch to continuous infusion of the loop diuretic

Common pitfall: Approximately 34% of hospitalized HFrEF patients require treatment escalation beyond initial IV diuretics, and failure to intensify therapy promptly leads to longer hospital stays and worse outcomes 2

Continuation of Chronic Oral Therapies

Maintain Guideline-Directed Medical Therapy During Hospitalization

• Continue ACE inhibitors/ARBs and beta-blockers in most patients experiencing HFrEF exacerbation, unless hemodynamic instability or specific contraindications exist 1
• This recommendation applies to patients already on these medications at admission 1

Critical consideration: Discontinuing these mortality-reducing therapies during hospitalization exposes patients to unnecessary risk, as they should only be held in cases of true hemodynamic instability (hypotension with hypoperfusion) 1

Management of Hypotension and Hypoperfusion

Inotropic Support Indications

• Administer IV inotropic agents (dobutamine) or vasopressors when hypotension is associated with hypoperfusion AND there is obvious evidence of elevated cardiac filling pressures (elevated JVP or pulmonary artery wedge pressure) 1, 3
• The goal is to maintain systemic perfusion and preserve end-organ function while pursuing definitive therapy 1
• Dobutamine is FDA-approved for short-term inotropic support in cardiac decompensation, though experience in controlled trials does not extend beyond 48 hours 3

Invasive Hemodynamic Monitoring

• Perform invasive hemodynamic monitoring in patients with respiratory distress or impaired perfusion when adequacy of intracardiac filling pressures cannot be determined clinically 1

Important caveat: IV nitroglycerin is FDA-approved for control of CHF in acute MI settings and can be used for afterload reduction 4, but avoid excessive vasodilation that compromises perfusion pressure.

Initiation of New Therapies Before Discharge

SGLT2 Inhibitors: Mandatory In-Hospital Initiation

• Initiate SGLT2 inhibitors (dapagliflozin or empagliflozin) in all stable hospitalized HFrEF patients before discharge 1, 5
• SGLT2 inhibitors provide clinical benefits that accrue rapidly within days to weeks, with minimal blood pressure effects and no excess kidney risk 1
• Deferring initiation to outpatient settings carries a >75% chance the medication will not be started within the next year 1
• Given that 1 in 4 patients hospitalized for HF die or are readmitted within 30 days, in-hospital initiation is critical 1

ACE Inhibitors/ARBs and Beta-Blockers for Treatment-Naïve Patients

• In patients not previously on ACE inhibitors/ARBs and beta-blockers, initiate these therapies in stable patients prior to hospital discharge 1
• Initiate beta-blockers only after volume optimization and successful discontinuation of IV diuretics, vasodilators, and inotropic agents 1
• Start at low doses in stable patients, with particular caution in those who required inotropes during hospitalization 1

Sacubitril/Valsartan Considerations

• For patients already on ACE inhibitors who remain symptomatic despite optimal therapy, consider switching to sacubitril/valsartan before discharge in hemodynamically stable patients 5
• Requires 36-hour washout period from ACE inhibitors to avoid angioedema 5
• Start at 24/26 mg twice daily in most hospitalized patients, with target dose of 97/103 mg twice daily 5

Monitoring and Transition to Oral Therapy

Daily Assessment Parameters

Monitor the following daily during hospitalization 1:

• Fluid intake and output measurements
• Vital signs including supine and standing blood pressure
• Body weight at the same time each day
• Clinical signs and symptoms of systemic perfusion and congestion
• Serum electrolytes, BUN, and creatinine during IV diuretic use

Transition to Oral Diuretics

• Transition from IV to oral diuretic therapy with careful attention to oral dosing and electrolyte monitoring 1
• Monitor for supine and upright hypotension, worsening renal function, and HF symptoms with all medication changes 1
• Approximately 61% of patients are successfully transitioned to oral diuretics before discharge 2

Critical pitfall: Approximately 26% of patients who are transitioned to oral diuretics require reinitiation of IV therapy during the same hospitalization, which is associated with 8-day median length of stay versus 4 days for uncomplicated courses 2

Medication Reconciliation and Discharge Planning

Comprehensive Medication Review

• Reconcile all medications on admission and at discharge 1
• Ensure adherence, persistence, and uptitration plans for ACE inhibitors/ARBs, beta-blockers, and SGLT2 inhibitors 1

Discharge Instructions

Provide comprehensive written discharge instructions emphasizing 1:

• Dietary sodium restriction
• Discharge medications with specific focus on adherence and uptitration schedules
• Activity level recommendations
• Follow-up appointment scheduling
• Daily weight monitoring protocols
• Action plan if HF symptoms worsen

Post-Discharge Care Coordination

• Utilize post-discharge systems of care when available to facilitate transition to effective outpatient care 1

Special Clinical Scenarios

Acute Myocardial Ischemia

• When patients present with acute HF and known or suspected acute MI due to occlusive coronary disease, especially with signs of inadequate perfusion, urgent cardiac catheterization and revascularization is reasonable where it is likely to prolong meaningful survival 1

Renal Function Considerations

• A rise in serum creatinine >25% of baseline during diuretic therapy represents an important adverse prognostic indicator 6
• Consider adding low-dose dopamine or adjusting diuretic strategy if significant renal deterioration occurs 6
• Do not withhold necessary diuretic therapy solely due to mild creatinine elevation if patient remains congested 1, 6