Treatment of CHF Exacerbation
Immediately initiate intravenous loop diuretics to relieve congestion, continue ACE inhibitors and beta-blockers unless the patient is hemodynamically unstable, and intensify diuretic therapy if initial response is inadequate by using higher doses, adding a second diuretic, or switching to continuous infusion. 1
Immediate Assessment and Monitoring
Assess volume status and perfusion clinically by examining jugular venous pressure, pulmonary congestion (rales, orthopnea), peripheral edema, and signs of hypoperfusion (cool extremities, altered mental status, oliguria). 1
Monitor fluid intake/output, daily weights at the same time each day, vital signs including supine and standing blood pressure, and measure serum electrolytes, blood urea nitrogen, and creatinine daily during active diuretic therapy or medication titration. 1
Use invasive hemodynamic monitoring (right heart catheterization) only when respiratory distress or impaired perfusion is present and adequacy of cardiac filling pressures cannot be determined clinically. 1
Diuretic Management: The Primary Intervention
Start with intravenous loop diuretics immediately as they provide rapid symptomatic relief by reducing pulmonary congestion and peripheral edema. 1, 2, 3
Titrate diuretic dose based on clinical response, serially assessing symptoms and signs of congestion to relieve symptoms and reduce extracellular fluid volume excess. 1
When diuresis is inadequate (persistent congestion on clinical evaluation), intensify the regimen using one of three strategies: 1
- Increase loop diuretic doses (higher than outpatient doses)
- Add a second diuretic such as metolazone, spironolactone, or intravenous chlorothiazide
- Switch to continuous infusion of loop diuretics
Ensure intravenous diuretic doses are at least equivalent to or higher than chronic oral doses to avoid underdosing, which is a common and dangerous pitfall. 2
Continuation of Guideline-Directed Medical Therapy
Continue ACE inhibitors or ARBs and beta-blockers during hospitalization in patients with reduced ejection fraction who are already on these therapies, unless hemodynamic instability or contraindications exist. 1, 2
Do not discontinue evidence-based heart failure medications prematurely during acute exacerbations, as this represents a critical error that worsens long-term outcomes. 2
For patients not previously on ACE inhibitors/ARBs and beta-blockers, initiate these therapies in stable patients prior to hospital discharge after optimization of volume status. 1
Initiate beta-blockers only after successful discontinuation of intravenous diuretics, vasodilators, and inotropic agents, starting at low doses with particular caution in patients who required inotropes. 1
Management of Hypotension with Hypoperfusion
Administer intravenous inotropic agents (dobutamine) or vasopressor drugs when clinical evidence shows hypotension associated with hypoperfusion AND obvious elevated cardiac filling pressures (elevated jugular venous pressure or pulmonary artery wedge pressure). 1, 4
Dobutamine is indicated for short-term inotropic support (experience does not extend beyond 48 hours) in cardiac decompensation due to depressed contractility. 4
Intravenous nitroglycerin is indicated for control of congestive heart failure in the setting of acute myocardial infarction or peri-operative hypertension. 5
Transition to Oral Therapy
Transition from intravenous to oral diuretics with careful attention to oral diuretic dosing, monitoring for supine and upright hypotension, worsening renal function, and heart failure signs/symptoms. 1
Reconcile all medications on admission and discharge, adjusting doses appropriately and ensuring patients receive comprehensive written discharge instructions. 1
Discharge Planning and Follow-Up
Provide comprehensive written discharge instructions emphasizing six critical aspects: diet (sodium restriction), discharge medications with focus on adherence and uptitration to target doses of ACE inhibitor/ARB and beta-blocker, activity level, follow-up appointments, daily weight monitoring, and what to do if symptoms worsen. 1
Utilize post-discharge systems of care when available to facilitate transition to effective outpatient care and reduce rehospitalization. 1
Critical Pitfalls to Avoid
Avoid premature discontinuation or underdosing of diuretics, which leaves patients congested and at high risk for readmission. 2
Do not stop ACE inhibitors or beta-blockers reflexively during acute exacerbations unless true hemodynamic instability exists (not just mild hypotension). 1, 2
Avoid excessive diuresis before initiating or uptitrating ACE inhibitors, as this increases risk of hypotension and renal dysfunction. 3, 6
Monitor for worsening renal function and electrolyte abnormalities (hypokalemia, hypomagnesemia, hyperkalemia if on aldosterone antagonists) during aggressive diuresis. 1, 3