What is the management approach for a patient with congestive heart failure (CHF) exacerbation and preserved ejection fraction in the inpatient setting?

Management of CHF Exacerbation with Preserved Ejection Fraction in the Inpatient Setting

For acute HFpEF exacerbation, immediately initiate intravenous loop diuretics at a dose equal to or exceeding the patient's chronic oral daily dose (or 40-80 mg IV furosemide if diuretic-naïve), titrate aggressively based on urine output to relieve congestion, and simultaneously start an SGLT2 inhibitor (dapagliflozin 10 mg daily or empagliflozin 10 mg daily) as disease-modifying therapy before discharge. 1, 2

Immediate Acute Management: Decongestion

Initial Diuretic Strategy

• Start IV loop diuretics immediately for all patients presenting with volume overload, pulmonary congestion, or peripheral edema 1, 2
• For patients already on oral diuretics: IV dose should equal or exceed their chronic oral daily dose 1
• For diuretic-naïve patients: initiate 40-80 mg IV furosemide (or equivalent) 2
• Monitor urine output hourly and titrate diuretic dose upward if inadequate response (target >100-150 mL/hour) 1, 3

Intensification for Inadequate Diuresis

If congestion persists despite initial therapy, escalate using one of three strategies 1:

• Increase loop diuretic dose (double the current dose)
• Add a second diuretic (metolazone 2.5-5 mg daily, spironolactone 25 mg daily, or IV chlorothiazide)
• Switch to continuous infusion of loop diuretic (5-10 mg/hour furosemide) 1, 3

Adjunctive Vasodilator Therapy

• In patients with severe symptomatic fluid overload WITHOUT hypotension, consider adding IV vasodilators (nitroglycerin, nitroprusside, or nesiritide) to diuretics 1
• This is particularly useful when diuretics alone provide inadequate symptom relief 1

Critical Monitoring During Acute Phase

Daily Assessment Requirements

Monitor the following parameters daily during active diuresis 1:

• Fluid intake and output (strict I&O charting)
• Daily weights (same time each day, same scale)
• Vital signs including orthostatic blood pressures
• Serum electrolytes, BUN, and creatinine (daily while on IV diuretics)
• Clinical signs of congestion: jugular venous distension, pulmonary rales, peripheral edema
• Signs of hypoperfusion: cool extremities, altered mental status, oliguria

When to Consider Invasive Hemodynamic Monitoring

Obtain right heart catheterization for 1:

• Respiratory distress with unclear volume status
• Clinical evidence of impaired perfusion where filling pressures cannot be determined clinically
• Persistent symptoms despite empiric therapy adjustments
• Hypotension with suspected elevated filling pressures
• Worsening renal function during therapy

Disease-Modifying Therapy: SGLT2 Inhibitors

Initiation Timing and Selection

• Start SGLT2 inhibitor during hospitalization once volume status is optimizing and patient is stable 1, 2
• First-line choice: Dapagliflozin 10 mg daily (requires eGFR >30 mL/min/1.73m²) OR Empagliflozin 10 mg daily (requires eGFR >60 mL/min/1.73m²) 1, 2
• These agents reduce HF hospitalizations by 21-29% and cardiovascular death 1, 2
• Do not delay initiation - these have proven mortality benefits and should be started before discharge 4, 2

Additional Pharmacotherapy Considerations

Mineralocorticoid Receptor Antagonists

• Consider spironolactone 12.5-25 mg daily particularly if LVEF is in the lower preserved range (45-50%) 1, 2
• Monitor potassium and creatinine closely (risk of hyperkalemia) 2
• Less robust evidence than SGLT2 inhibitors but may reduce HF hospitalizations 1, 2

Angiotensin Receptor-Neprilysin Inhibitors

• Sacubitril/valsartan may be considered (Class 2b recommendation) for selected patients, particularly women and those with LVEF 45-57% 1, 2
• Weaker evidence than SGLT2 inhibitors; reserve for specific subgroups 1, 2

Management of Existing Medications

• Continue ACE inhibitors/ARBs and beta-blockers if patient was on them chronically, unless hemodynamic instability or contraindications exist 1
• Do NOT initiate beta-blockers during acute decompensation 1
• If beta-blocker initiation is needed, wait until after volume optimization and discontinuation of IV diuretics/vasodilators 1

Transition to Oral Therapy

Converting from IV to Oral Diuretics

• Transition carefully from IV to oral diuretics with attention to equivalent dosing 1
• Typical conversion: IV furosemide to oral furosemide is approximately 1:2 ratio (e.g., 40 mg IV = 80 mg oral) 1
• Monitor closely for 24-48 hours after transition for adequate diuresis, electrolyte abnormalities, and orthostatic hypotension 1

Management of Comorbidities

Hypertension

• Target blood pressure <130/80 mmHg using evidence-based antihypertensives 4, 2
• Optimize during hospitalization as tolerated by volume status 2

Atrial Fibrillation (if present)

• Rate control is preferred over rhythm control strategy 4, 5
• Beta-blockers are first-line for rate control 4
• Non-dihydropyridine calcium channel blockers (diltiazem) can be used, especially with digoxin 4
• Anticoagulate based on CHA₂DS₂-VASc score 5

Diabetes

• Prefer SGLT2 inhibitors for dual benefit (diabetes control + HF outcomes) 2, 5

Common Pitfalls to Avoid

• Avoid excessive diuresis leading to hypotension, prerenal azotemia, and worsening renal function 2
• Do not treat HFpEF identically to HFrEF - response to therapies differs significantly 2
• Do not delay SGLT2 inhibitor initiation - these should be started before discharge in stable patients 4, 2
• Do not start beta-blockers during acute decompensation - wait until euvolemic and off IV therapies 1
• Do not overlook comorbidity management - hypertension, diabetes, obesity, and sleep apnea significantly impact outcomes 4, 2, 6

Discharge Planning

Comprehensive Discharge Instructions (Mandatory)

Provide written instructions covering these six critical areas 1:

1. Diet: Sodium restriction (typically <2-3 g/day)
2. Medications: Emphasize adherence, include SGLT2 inhibitor
3. Activity level: Encourage gradual increase as tolerated
4. Follow-up appointments: Schedule within 7-14 days
5. Daily weight monitoring: Call physician if gain >2-3 lbs in 1 day or >5 lbs in 1 week
6. What to do if symptoms worsen: Clear action plan

Post-Discharge Systems

• Utilize post-discharge care systems if available (home health, telemonitoring, HF clinic follow-up) to facilitate transition 1
• Early outpatient follow-up reduces readmission rates 1

Medication Reconciliation

• Reconcile all medications on admission and discharge 1
• Ensure SGLT2 inhibitor is prescribed and patient understands its importance 1, 2
• Adjust diuretic dose to lowest effective maintenance dose 2