What are the management steps for a 55-year-old male with a cut, chronic heart failure (CHF) exacerbation, ejection fraction of 35%, hypertension, chronic obstructive pulmonary disease (COPD), and a history of atrial fibrillation on Eliquis (apixaban)?

Management of Acute CHF Exacerbation with Multiple Comorbidities

For this 55-year-old male with acute CHF exacerbation (EF 35%), hypertension (BP 155/92), COPD, and atrial fibrillation on Eliquis, initiate immediate IV loop diuretics without delay, optimize volume status while maintaining his anticoagulation, control his blood pressure with existing guideline-directed medical therapy optimization, and manage his atrial fibrillation with rate control—all while carefully monitoring for diuretic resistance and avoiding excessive diuresis that could worsen renal function. 1, 2

Immediate Assessment and Monitoring

Establish baseline parameters immediately:

• Measure fluid intake/output, vital signs, daily weight, and assess signs of systemic perfusion and congestion 2
• Monitor oxygen saturation continuously for at least 24 hours; maintain SpO2 >90% at all times 3
• Check serum electrolytes, BUN, creatinine, and troponin on admission 1, 2
• Obtain chest X-ray, ECG, and echocardiography to assess volume status and rule out acute coronary syndrome 1
• Measure BNP or NT-proBNP to confirm heart failure diagnosis and establish baseline 1

Identify precipitating factors for this exacerbation:

• Hypertension (BP 155/92) is a clear precipitant requiring immediate attention 1
• Assess for atrial fibrillation rate control adequacy 1
• Rule out acute coronary syndrome, infection, pulmonary embolism, medication non-compliance, and COPD exacerbation 1

Immediate Diuretic Management

Start IV loop diuretics immediately in the emergency department:

• Administer IV furosemide at a dose equal to or exceeding 2-2.5 times his chronic oral daily dose 1, 2, 4
• Early intervention is associated with better outcomes in hospitalized patients with decompensated heart failure 1

Monitor diuretic response closely:

• Assess spot urine sodium at 2 hours (target >50-70 mmol/L) or urine output in first 6 hours (target >100-150 mL/h) 4
• Target weight loss of 0.5-1.5 kg in 24 hours 4
• Monitor daily serum electrolytes, BUN, and creatinine during IV diuretic therapy 2

If inadequate diuresis occurs within 24-48 hours despite optimized loop diuretic dosing:

• Consider sequential nephron blockade by adding a thiazide-type diuretic (e.g., metolazone or hydrochlorothiazide) 1
• Alternatively, add acetazolamide as a carbonic anhydrase inhibitor to augment diuresis 1
• Consider continuous IV furosemide infusion (starting at 5-10 mg/hour) if bolus dosing proves inadequate 5
• Caution: Monitor closely for worsening renal function with combination diuretic therapy, though modest creatinine elevation may not indicate true tubular injury 1

Blood Pressure Management

Address hypertension (155/92 mmHg) through optimization of existing therapy:

• Continue and optimize ACE inhibitors or ARBs (first-line for HFrEF with hypertension) 1
• Ensure beta-blocker therapy is continued unless contraindicated by acute decompensation 2
• The IV loop diuretics will help reduce preload and blood pressure 1
• If hypertension persists after optimizing ACE inhibitors/ARBs, beta-blockers, and diuretics, consider adding spironolactone (12.5-50 mg daily) 1

Do not abruptly discontinue beta-blockers during hospitalization:

• Continue chronic beta-blocker therapy in patients with reduced ejection fraction unless hemodynamically unstable 2

Atrial Fibrillation Management

Continue anticoagulation with Eliquis (apixaban):

• Do not discontinue anticoagulation unless active bleeding occurs 6
• Apixaban should be continued at his prescribed dose for stroke prevention in atrial fibrillation 6

Ensure adequate rate control:

• Target heart rate control with beta-blockers as first-line (already indicated for HFrEF) 1
• If beta-blockers alone are insufficient, add digoxin for rate control 1
• Avoid rhythm control strategies during acute decompensation; focus on rate control 1

COPD Management During Hospitalization

Optimize respiratory status without worsening heart failure:

• Administer supplemental oxygen to maintain SpO2 >90% 3
• Continue inhaled bronchodilators (long-acting anticholinergics or beta-agonists) for symptomatic COPD 1
• If respiratory distress persists despite oxygen therapy, consider non-invasive ventilation (CPAP or BiPAP) which improves cardiac hemodynamics and oxygenation 2
• Avoid excessive IV fluids that could worsen pulmonary congestion 3

Hemodynamic Support (If Needed)

Only if hypotension with hypoperfusion develops:

• Administer IV inotropic agents (dobutamine 2.5-5 μg/kg/min) or vasopressors to maintain systemic perfusion 1, 3, 2
• Consider pulmonary artery catheterization if refractory to pharmacological treatment or persistently hypotensive 3
• Note: This patient is currently hypertensive, so inotropic support is not indicated at present 1

Monitoring for Complications

Watch for diuretic resistance and renal dysfunction:

• Diuretic resistance is associated with poor outcomes including worsening kidney function and mortality 1
• If serum creatinine rises >25% from baseline, reassess volume status and consider reducing diuretic intensity 7
• Hypochloremia and metabolic alkalosis antagonize loop diuretic effects; monitor electrolytes closely 1

Avoid excessive diuresis:

• Overly aggressive diuresis can cause hypotension, hypoperfusion, and tubular injury 7
• Balance decongestion goals against risk of cardiorenal syndrome 1, 7

Discharge Planning

Before discharge, ensure:

• Acute episode has resolved with absent congestion 3
• Stable oral diuretic regimen established for at least 48 hours 3
• Guideline-directed medical therapy optimized (ACE inhibitor/ARB, beta-blocker, consider adding SGLT2 inhibitor and/or spironolactone) 2
• Comprehensive written discharge instructions provided covering diet (sodium restriction), medications, daily weight monitoring, activity level, and follow-up appointments 2
• Arrange early follow-up (within 7-14 days) and consider enrollment in multidisciplinary heart failure management program 2