What is the acute and discharge management for a patient with congestive heart failure (CHF) with reduced ejection fraction (EF) less than 45%?

Management of Acute-on-Chronic Heart Failure with Reduced Ejection Fraction (EF <45%)

For this 55-year-old female with HFrEF presenting in acute decompensation, initiate aggressive IV loop diuretics to achieve euvolemia while continuing her existing ACE inhibitor/ARB and beta-blocker therapy unless hemodynamically unstable, then ensure she is discharged on optimized quadruple guideline-directed medical therapy (GDMT) including ACE inhibitor/ARB (or ARNI), beta-blocker, mineralocorticoid receptor antagonist, and SGLT2 inhibitor. 1

Acute Management (In-Hospital)

Initial Assessment and Monitoring

• Daily monitoring requirements: 1
  • Body weight at the same time each day
  • Fluid intake and output with accurate balance chart
  • Vital signs including supine and standing blood pressure
  • Daily serum electrolytes, urea nitrogen, and creatinine during IV diuretic use
  • Clinical assessment of perfusion and congestion status

Diuretic Therapy (Primary Acute Intervention)

• Initial IV loop diuretic dosing: The IV dose should equal or exceed the patient's chronic oral daily dose 1
• Titration strategy: Serially assess urine output and congestion signs, adjusting dose to relieve symptoms and reduce extracellular fluid volume 1
• If inadequate diuresis occurs, intensify using: 1
  • Higher doses of loop diuretics, OR
  • Addition of second diuretic (metolazone, spironolactone, or IV chlorothiazide), OR
  • Continuous infusion of loop diuretic

Vasodilator Therapy

• For severe fluid overload without systemic hypotension: IV vasodilators such as nitroglycerin are reasonable 1

Management of Hypotension with Hypoperfusion

• If clinical hypotension with hypoperfusion AND elevated filling pressures (elevated JVP or PCWP): Administer IV inotropic or vasopressor drugs to maintain systemic perfusion and preserve end-organ performance 1
• Consider invasive hemodynamic monitoring in patients with respiratory distress or impaired perfusion when filling pressure adequacy cannot be determined clinically 1

Critical Medication Management During Hospitalization

• Continue existing GDMT: In patients already on ACE inhibitors/ARBs and beta-blockers, continue these therapies during hospitalization in the absence of hemodynamic instability or contraindications 1
  • This is crucial as these medications improve outcomes even during acute exacerbations
  • Common precipitants include medication non-compliance (15% of exacerbations), inappropriate reductions in HF therapy (10%), and use of negative inotropes like calcium channel blockers (13%) 2

Avoid Harmful Medications

• Calcium channel blockers should be avoided in HFrEF due to negative inotropic effects 3
  • A study demonstrated significantly higher incidence of worsening heart failure symptoms with IV diltiazem compared to metoprolol (33% vs 15%, p=0.019) 3

Transition to Oral Therapy

• Before discharge: Transition from IV to oral diuretics with careful attention to dosing and electrolyte monitoring 1
• Monitor for: Supine and upright hypotension, worsening renal function, and HF signs/symptoms with all medication changes 1

Discharge Management

Discharge Readiness Criteria

Patient is medically fit for discharge when: 1

• Hemodynamically stable for at least 24 hours
• Euvolemic (congestion resolved)
• Established on evidence-based oral medications
• Stable renal function for at least 24 hours before discharge
• Provided with tailored education and self-care advice

Quadruple GDMT Optimization (The Four Pillars)

All four medication classes should be initiated prior to discharge if not already prescribed: 1, 4

1. ACE Inhibitor/ARB or ARNI

   • Initiate in stable patients prior to hospital discharge if not already on therapy 1
   • ARNI (angiotensin receptor-neprilysin inhibitor) is preferred over ACE inhibitor/ARB when tolerated 4
   • Example: Lisinopril starting at low doses, with target of higher doses (up to 35 mg showed favorable outcomes) 5

2. Beta-Blocker

   • Initiate after volume optimization and successful discontinuation of IV diuretics, vasodilators, and inotropic agents 1
   • Start at low dose in stable patients only
   • Use particular caution in patients who required inotropes during hospitalization 1
   • Approved agents: bisoprolol, carvedilol, sustained-release metoprolol succinate, or nebivolol 1

3. Mineralocorticoid Receptor Antagonist (MRA)

   • Should be part of the discharge regimen 1, 4
   • Spironolactone is commonly used

4. SGLT2 Inhibitor

   • Now a cornerstone of HFrEF therapy regardless of diabetes status 1, 4
   • Should be initiated before discharge as part of quadruple therapy

Comprehensive Discharge Instructions

Provide written instructions emphasizing these six critical aspects: 1

1. Diet: Salt and fluid restriction 6
2. Discharge medications: Focus on adherence, persistence, and uptitration to recommended doses of ACE inhibitor/ARB and beta-blocker
3. Activity level: Regular physical activity recommended 6
4. Follow-up appointments: Specific scheduling (see below)
5. Daily weight monitoring: Same time each day
6. Action plan: What to do if HF symptoms worsen

Post-Discharge Follow-Up Structure

Mandatory follow-up timeline: 1

• Within 3 days: Telephone follow-up
• Within 1 week: Visit with general practitioner
• Within 2 weeks: Visit with hospital cardiology team
• Ongoing: Enrollment in disease management program and multi-professional heart failure service for continuation and uptitration of GDMT

Prognostic Monitoring

• Pre-discharge natriuretic peptide measurement is useful for post-discharge planning 1
  • Patients whose natriuretic peptide concentrations fall during admission have lower cardiovascular mortality and readmission rates at 6 months 1

Common Pitfalls to Avoid

• Do not discontinue beta-blockers or ACE inhibitors/ARBs during acute exacerbation unless true hemodynamic instability exists 1
• Do not delay GDMT initiation until outpatient follow-up—stable patients should have all four pillars started before discharge 1, 4
• Do not use calcium channel blockers for rate control in atrial fibrillation with HFrEF—use beta-blockers instead 3
• Address medication non-compliance and salt restriction non-compliance, which together account for a substantial proportion of acute exacerbations 2