What is the treatment for congestive heart failure (CHF) exacerbation?

Treatment for CHF Exacerbation

Immediately administer intravenous loop diuretics within 60 minutes of presentation, starting with 20-40 mg IV furosemide for diuretic-naïve patients or double the patient's home oral dose for those on chronic therapy, and assess diuretic response at 2 hours (spot urine sodium ≥50-70 mmol/L) and 6 hours (urine output ≥100-150 mL/hour) to guide further escalation. 1, 2

Initial Assessment and Risk Stratification

• Measure plasma natriuretic peptide levels (BNP or NT-proBNP) immediately in all patients with acute dyspnea to confirm acute heart failure versus non-cardiac causes 1
• Perform ECG and echocardiography urgently, particularly if cardiogenic shock is suspected 1
• Assess vital signs, body weight, and clinical signs of systemic perfusion (cool extremities, altered mental status) and congestion (jugular venous distension, peripheral edema, pulmonary rales) 1

Immediate Diuretic Therapy

Initial Dosing Strategy

• For patients NOT on chronic oral diuretics: Start with 20-40 mg IV furosemide 1
• For patients on chronic oral diuretics: Administer at least double their home oral dose as the initial IV dose 1, 2
• The door-to-diuretic time should not exceed 60 minutes 2

Early Response Assessment (Critical for Success)

• At 2 hours: Check spot urinary sodium—target is ≥50-70 mmol/L 1, 2, 3
• At 6 hours: Assess urine output—target is ≥100-150 mL/hour 1, 2, 3
• At 24 hours: Target weight loss of 0.5-1.5 kg and total urine output of 3-5 L 3

Escalation for Inadequate Diuretic Response

Step 1: Increase Loop Diuretic Dose

• If targets are not met at 2 or 6 hours, double the loop diuretic dose 1
• Maximum recommended furosemide dose is typically 400-600 mg/day, though up to 1000 mg/day may be used in severe renal dysfunction 2
• Continuous infusion of loop diuretics offers no advantage over intermittent boluses based on the DOSE trial 2

Step 2: Add Sequential Nephron Blockade

If congestion persists after maximizing loop diuretics over 24-48 hours, add a second diuretic agent:

• Acetazolamide 500 mg IV once daily is particularly effective when baseline bicarbonate ≥27 mmol/L and remains effective despite worsening renal function 1, 2, 3

  • Use only for the first 3 days to prevent severe metabolic disturbances 2
  • Recent ADVOR and CLOROTIC trials support early combination therapy with acetazolamide 2

• Metolazone 2.5-10 mg orally once daily or IV chlorothiazide 500-1000 mg are alternatives 4, 1

  • Note: Metolazone produces the highest natriuresis (4,691 mg sodium vs 3,835 mg with furosemide alone) but carries significantly higher risk of worsening renal function (39% vs 16% with furosemide alone) 5

• Spironolactone 12.5-25 mg daily can be added, especially if hypokalemia is present 4, 1

Monitoring During Aggressive Diuresis

• Measure serum electrolytes, urea nitrogen, and creatinine daily during IV diuretic use or active medication titration 1
• Monitor for hypokalemia, hypomagnesemia, and worsening renal function 1, 2
• Track daily weights, urine output, and clinical signs of congestion 1

Continuation of Evidence-Based Therapies

During Hospitalization

• Continue ACE inhibitors/ARBs and beta-blockers (bisoprolol, carvedilol, or metoprolol succinate) unless the patient is hemodynamically unstable or hypotensive 1, 6
• Attempting to continue disease-modifying therapies in patients with chronic HFrEF is recommended by the European Society of Cardiology 1
• If hypotension occurs during beta-blocker therapy, reduce vasodilators first rather than the beta-blocker 6

Before Discharge

• Initiate or optimize guideline-directed medical therapy including ACE inhibitors/ARBs (or ARNI), beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors for patients with HFrEF 1, 6
• Do not discharge patients while still congested—residual congestion at discharge is associated with poor prognosis 2

Special Considerations and Contraindications

Inotropic Support

• Reserve inotropic agents (such as dobutamine) only for patients who are symptomatically hypotensive or hypoperfused despite adequate filling pressures 1, 7
• Dobutamine is indicated for short-term use (experience does not extend beyond 48 hours) in cardiac decompensation due to depressed contractility 7
• Long-term use of inotropes has been associated with increased hospitalization and death in controlled trials 7

Medications to Avoid

• NSAIDs and COX-2 inhibitors increase risk of heart failure worsening and hospitalization 1
• Thiazolidinediones (glitazones) increase risk of heart failure worsening 1
• Nondihydropyridine calcium channel blockers may be harmful in patients with low LVEF 4

Transition to Oral Therapy and Discharge Planning

• Transition from IV to oral diuretic therapy with careful attention to equivalent oral dosing and continued electrolyte monitoring 1
• Provide comprehensive discharge instructions covering:
  • Sodium restriction (reasonable for symptomatic patients) 4, 1
  • Daily weight monitoring with instructions to contact provider if weight increases >2-3 pounds in 24 hours 1
  • Medication adherence and recognition of worsening symptoms 1
  • Follow-up appointments within 2 weeks for up-titration of guideline-directed medical therapy (STRONG-HF trial) 2
• Enroll patients in a multidisciplinary care management program to reduce rehospitalization and mortality 1

Common Pitfalls to Avoid

• Underdosing diuretics: Ensure IV dose is at least equivalent to (and typically double) the oral home dose 1, 2
• Delayed diuretic administration: Door-to-diuretic time should not exceed 60 minutes 2
• Failing to assess early diuretic response: Without 2-hour and 6-hour assessments, inadequate diuresis may persist for days 1, 2
• Discontinuing evidence-based therapies unnecessarily: Continue ACE inhibitors/ARBs and beta-blockers unless hemodynamically unstable 1, 6
• Inadequate electrolyte monitoring: Failure to monitor potassium, magnesium, and renal function during aggressive diuresis can lead to dangerous complications 1, 2
• Discharging with residual congestion: This is strongly associated with early readmission 2