Which Guideline-Directed Therapeutic Medication (GDTM) for heart failure can be started during an acute exacerbation?

ACE Inhibitors/ARNIs Should Be Continued During Acute Heart Failure Exacerbations

ACE inhibitors (or ARBs) should be continued during acute heart failure exacerbations, as it is very rarely necessary to stop them and clinical deterioration is likely if treatment is withdrawn. 1 In contrast, beta-blockers should generally be held during the acute phase and only restarted after stabilization and achieving euvolemia. 1

The Critical Distinction: ACE Inhibitors vs. Beta-Blockers

ACE Inhibitors/ARNIs: Continue Through Exacerbation

• ACE inhibitors should almost never be stopped during acute decompensation, and specialist advice should be sought before any treatment discontinuation. 1
• The evidence strongly supports maintaining renin-angiotensin system blockade even during acute illness, as withdrawal leads to clinical deterioration. 1
• For patients on sacubitril/valsartan (ARNI), the PIONEER-HF trial demonstrated that this medication can be safely initiated during hospitalization for acute decompensated heart failure after stabilization, showing superior outcomes compared to enalapril regardless of prior ACE inhibitor/ARB use. 2

Beta-Blockers: Hold and Restart After Stabilization

• Beta-blockers require caution during current or recent (<4 weeks) exacerbation of heart failure, including hospital admission with worsening HF. 1
• Guidelines explicitly state to relieve congestion and achieve euvolemia before starting or continuing beta-blockers. 1
• In hospitalized patients with worsening HF, beta-blockers should be restarted after stabilizing, relieving congestion, and restoring euvolemia (but ideally before discharge). 1

Practical Algorithm for Acute Exacerbation

Medications to CONTINUE:

• ACE inhibitors or ARBs: Maintain current dose unless severe hypotension (systolic <90 mmHg) or acute kidney injury develops. 1
• Diuretics: Increase dose aggressively to relieve congestion. 1

Medications to HOLD Temporarily:

• Beta-blockers: Hold if signs of congestion persist (raised JVP, ascites, marked peripheral edema). 1
• MRAs (spironolactone/eplerenone): Consider holding if significant renal dysfunction or hyperkalemia develops. 1

Restart Sequence After Stabilization:

1. First priority: Ensure ACE inhibitor/ARNI is at optimal dose (never stopped). 1
2. Second priority: Restart beta-blocker at low dose once euvolemic, before hospital discharge. 1
3. Third priority: Resume MRA once renal function and potassium are stable. 3

Common Pitfalls to Avoid

• Do not reflexively stop ACE inhibitors during acute exacerbations due to mild creatinine elevation or asymptomatic hypotension—these medications are protective and withdrawal causes harm. 1
• Do not continue beta-blockers if the patient has persistent congestion, as this will worsen outcomes; wait until euvolemia is achieved. 1
• Do not delay restarting beta-blockers once stabilized—they should be reinitiated before discharge, not weeks later in outpatient follow-up. 1
• Avoid NSAIDs during acute exacerbations, as they cause diuretic resistance and worsen renal function. 1

Monitoring During Acute Phase

• Check blood pressure, renal function (creatinine/BUN), and electrolytes (potassium) within 1-2 weeks after any medication adjustment. 1, 3
• If creatinine rises significantly, check for hypovolemia/dehydration and exclude nephrotoxic agents before stopping ACE inhibitors. 1
• For symptomatic hypotension without congestion, consider reducing diuretic dose rather than stopping ACE inhibitors. 1