What are the treatment guidelines for a patient with a history of congestive heart failure (CHF) with or without reduced ejection fraction, experiencing an exacerbation with worsening symptoms such as dyspnea, fatigue, or edema?

Treatment Guidelines for CHF Exacerbation

Immediate Management of Acute Decompensation

For patients presenting with acute CHF exacerbation, initiate intravenous loop diuretics immediately at a dose equal to or exceeding their chronic oral daily dose, with continuous reassessment of urine output and congestion signs to guide dose titration. 1

Initial Diuretic Strategy

• Start IV furosemide at a dose that equals or exceeds the patient's chronic oral daily dose—if they take 40 mg oral furosemide daily, begin with at least 40 mg IV 1
• Monitor response by measuring urine output, daily weights (same time each day), vital signs, and clinical signs of congestion (jugular venous pressure, peripheral edema, pulmonary rales) 1
• Intensify diuresis if congestion persists despite initial therapy using one of three approaches: (1) higher doses of loop diuretics, (2) addition of a second diuretic such as metolazone or IV chlorothiazide, or (3) continuous infusion of loop diuretics 1

Hemodynamic Assessment and Support

• For hypotension with hypoperfusion (cool extremities, altered mental status) AND elevated filling pressures (elevated JVP, pulmonary congestion), administer IV inotropic or vasopressor drugs to maintain systemic perfusion while pursuing definitive therapy 1
• Use invasive hemodynamic monitoring (pulmonary artery catheter) when respiratory distress or impaired perfusion is present and adequacy of filling pressures cannot be determined clinically 1

Continuation of Guideline-Directed Medical Therapy During Hospitalization

Continue ACE inhibitors/ARBs and beta-blockers during hospitalization in most patients unless hemodynamic instability or specific contraindications exist. 1

Medication Management During Acute Phase

• Maintain chronic HF medications including ACE inhibitors/ARBs and beta-blockers unless the patient has hemodynamic instability (systolic BP <80 mmHg with symptomatic hypotension) 1
• Reconcile all medications on admission and discharge, adjusting doses as appropriate based on clinical status 1
• Monitor daily serum electrolytes, blood urea nitrogen, and creatinine during IV diuretic use or active medication titration 1

Identifying and Addressing Precipitants

Systematically evaluate for reversible precipitating factors that commonly trigger CHF exacerbations, as addressing these is critical to preventing recurrence. 2

• Dietary sodium non-compliance accounts for 22% of exacerbations—reinforce salt restriction counseling 2
• Pulmonary infections and other non-cardiac causes represent 20% of cases—treat underlying infections aggressively 2
• Medication non-adherence or inappropriate reductions in HF therapy cause 10-15% of exacerbations—review medication adherence and ensure patients understand the importance of continuing therapy 2
• Arrhythmias (13%), particularly atrial fibrillation with rapid ventricular response—control rate and consider rhythm management 2
• Calcium channel blockers (13%) and antiarrhythmic agents (15%)—discontinue non-essential cardiotoxic medications 2

Optimization Before Discharge

Initiate or optimize all four foundational medication classes (SGLT2 inhibitor, MRA, beta-blocker, and ARNI/ACE inhibitor/ARB) in stable patients prior to hospital discharge. 1, 3

Pre-Discharge Medication Optimization

• For patients not on optimal therapy, initiate evidence-based medications once volume status is optimized and IV diuretics/vasodilators/inotropes are discontinued 1
• Start beta-blockers at low doses only after the patient is stable, euvolemic, and off IV support—particular caution is required with beta-blocker initiation in the acute setting 1
• Transition from IV to oral diuretics carefully, with attention to oral diuretic dosing and monitoring for supine/upright hypotension, worsening renal function, and recurrent HF symptoms 1

Specific Medication Recommendations

• SGLT2 inhibitors (dapagliflozin or empagliflozin) should be added if not already prescribed, as they reduce cardiovascular death and HF hospitalization with minimal blood pressure effects, making them ideal for early initiation 3
• Mineralocorticoid receptor antagonists (spironolactone or eplerenone) provide at least 20% mortality reduction and should be used in all symptomatic patients with LVEF ≤35% if eGFR >30 mL/min/1.73 m² 3
• Sacubitril/valsartan (ARNI) is preferred over ACE inhibitors, providing superior mortality reduction of at least 20% in symptomatic patients 3
• Evidence-based beta-blockers (carvedilol, metoprolol succinate, or bisoprolol) reduce mortality by at least 20% and should be titrated to target doses 3

Discharge Planning and Transition of Care

Provide comprehensive written discharge instructions emphasizing six critical aspects: diet, medications, activity level, follow-up appointments, daily weight monitoring, and symptom management. 1

Essential Discharge Components

• Medication education with special focus on adherence, persistence, and up-titration plans for ACE inhibitor/ARB and beta-blocker to recommended doses 1
• Daily weight monitoring with instructions to contact provider if weight increases by 2-3 pounds in one day or 5 pounds in one week 1
• Sodium restriction counseling, as non-compliance is the most common precipitant of readmission 2
• Post-discharge systems of care should be utilized when available to facilitate transition to effective outpatient care 1

Common Pitfalls to Avoid

• Never discontinue GDMT for asymptomatic hypotension—these medications maintain efficacy even with systolic BP <110 mmHg 3
• Avoid excessive diuresis before initiating ACE inhibitors, which can precipitate hypotension and renal dysfunction 1
• Do not use non-evidence-based beta-blockers or calcium channel blockers (diltiazem, verapamil) in HFrEF, as they increase risk of worsening heart failure 3
• Avoid combining ACE inhibitor with ARB and MRA (triple RAAS blockade) due to hyperkalemia and renal dysfunction risk 3
• Never delay initiation of all four foundational medication classes once the patient is stable—simultaneous initiation is now recommended 3