What is the immediate management for a patient with preserved Ejection Fraction (EF) congestive heart failure (CHF), right ventricular dysfunction (RVD), and hypertensive urgency?

Immediate Management of HFpEF with RVR and Hypertensive Urgency

For a patient with preserved ejection fraction heart failure presenting with rapid ventricular response and hypertensive urgency, immediately initiate IV loop diuretics for decongestion, aggressively control heart rate with IV beta-blockers (avoiding non-dihydropyridine calcium channel blockers), and lower blood pressure by approximately 25% within 1-2 hours using IV agents that don't worsen heart failure. 1, 2, 3

Immediate Priorities (First 1-2 Hours)

1. Aggressive Decongestion

• Start IV loop diuretics immediately at a dose equal to or exceeding the patient's chronic oral daily dose, or 40-80 mg IV furosemide if diuretic-naïve 2
• Target urine output >100-150 mL/hour and titrate upward aggressively if inadequate response 2
• Monitor hourly urine output and adjust dosing accordingly 2

2. Rate Control for RVR

• Use IV beta-blockers as first-line for rate control in atrial fibrillation with RVR 1, 4
• Avoid diltiazem and verapamil (non-dihydropyridine calcium channel blockers) as they have negative inotropic properties and increase risk of worsening heart failure and hospitalization in HFpEF 1, 5
• Alternative: Consider IV digoxin if beta-blockers are contraindicated, as the RATE-AF trial showed similar quality of life outcomes between bisoprolol and digoxin in elderly HFpEF patients with AF 1

3. Blood Pressure Management

• Lower blood pressure by approximately 25% within 1-2 hours to prevent progression of target organ damage 3
• Use IV agents that preserve cardiac function:
  • IV enalaprilat (the only parenteral ACE inhibitor) is particularly useful in HFpEF with hypertensive urgency 6
  • IV nicardipine (a dihydropyridine calcium channel blocker) is safe in HFpEF, unlike non-dihydropyridines 1, 6
  • IV fenoldopam offers the advantage of improving renal blood flow 6
• Caution: Avoid excessive volume depletion before using ACE inhibitors, as they may cause precipitous blood pressure drops in hypovolemic patients 6

Critical Monitoring During Acute Phase

• Assess hourly: Urine output, vital signs, heart rate control 2
• Assess daily: Fluid intake/output, daily weights, serum electrolytes, BUN, creatinine 2
• Clinical assessment: Signs of congestion (jugular venous distention, pulmonary rales, peripheral edema) and signs of hypoperfusion (cool extremities, narrow pulse pressure) 1

Common Pitfalls to Avoid

• Do not use non-dihydropyridine calcium channel blockers (diltiazem, verapamil) for rate control, as they worsen outcomes in HFpEF 1, 5
• Avoid alpha-blockers (doxazosin), which doubled the risk of developing heart failure in the ALLHAT trial 1
• Use diuretics cautiously as prior volume depletion may be present in hypertensive urgency 6
• Avoid excessive diuresis leading to hypotension and worsening renal function 5
• Monitor for hyperkalemia if using ACE inhibitors or considering aldosterone antagonists 1

Transition Phase (24-48 Hours)

1. Initiate Disease-Modifying Therapy

• Start SGLT2 inhibitor (dapagliflozin 10 mg or empagliflozin 10 mg daily) once volume status is optimizing and patient is stable 2, 5
• These reduce HF hospitalizations by 21-29% and should be started before discharge 2, 5
• Ensure eGFR >30 mL/min/1.73m² for dapagliflozin 5

2. Optimize Blood Pressure Control

• Target blood pressure <130/80 mmHg using evidence-based antihypertensives 1, 5
• First-line agents for long-term BP control in HFpEF: RAAS antagonists (ACE inhibitors, ARBs, or ARNIs), which have experience in HFpEF trials 1
• Consider adding spironolactone 12.5-25 mg daily if LVEF is in the lower preserved range (45-50%), with close monitoring of potassium and creatinine 2, 5

3. Transition to Oral Diuretics

• Transition carefully from IV to oral diuretics with attention to equivalent dosing 2
• Monitor closely for 24-48 hours after transition for adequate diuresis, electrolyte abnormalities, and orthostatic hypotension 2
• Adjust to the lowest effective maintenance dose 2

Atrial Fibrillation Management

• Anticoagulation based on CHA₂DS₂-VASc score 1, 4
• Rate control strategy preferred over rhythm control in most HFpEF patients 1
• Beta-blockers remain first-line for chronic rate control 1, 4

Discharge Planning

• Ensure SGLT2 inhibitor is prescribed and patient understands its importance 2
• Provide comprehensive discharge instructions: diet (sodium restriction), medications, daily weight monitoring, activity level, follow-up appointments 2
• Medication reconciliation on discharge with appropriate diuretic dose adjustment 2
• Arrange early follow-up (within 7 days) to assess volume status and medication tolerance 1

Additional Considerations for Selected Patients

• Sacubitril/valsartan may be considered particularly for women and those with LVEF 45-57%, though evidence is weaker than for SGLT2 inhibitors 1, 2, 5
• Treat underlying coronary disease if ischemia is contributing to decompensation 1
• Consider cardiac amyloidosis screening in appropriate clinical contexts, as it is a specific treatable cause of HFpEF 1