Hydrocortisone Has No Established Role in Standard Heart Failure Treatment
Hydrocortisone (cortisol) is not recommended for the routine treatment of heart failure, including acute decompensated heart failure, as major international guidelines do not include corticosteroids in their therapeutic algorithms and the FDA label warns of significant cardiovascular risks. 1, 2
Guideline-Based Standard of Care
The cornerstone pharmacotherapy for acute decompensated heart failure consists of:
- IV loop diuretics (furosemide 20-40 mg IV for diuretic-naïve patients, or at least equivalent to oral dose for those on chronic therapy) as first-line treatment to reduce congestion 1
- Continuation of disease-modifying therapies (ACE inhibitors/ARBs, beta-blockers, mineralocorticoid receptor antagonists) unless hemodynamic instability exists 1
- Vasodilators for symptomatic relief in patients with adequate blood pressure 1
- Inotropic agents are NOT recommended unless the patient is symptomatically hypotensive or hypoperfused due to safety concerns 1
Notably absent from all major guidelines (ESC 2016, AHA/ACC/HFSA 2022) is any mention of corticosteroids as a therapeutic option for heart failure. 1
FDA-Labeled Cardiovascular Risks
The FDA label for hydrocortisone explicitly warns of multiple cardiovascular complications:
- Salt and water retention with increased potassium excretion, particularly problematic in heart failure patients 2
- Elevation of blood pressure, which can worsen cardiac afterload 2
- Association with left ventricular free wall rupture after recent myocardial infarction, requiring great caution in these patients 2
- Cardiac enlargement and congestive heart failure when combined with amphotericin B 2
- Should be used with caution in patients with congestive heart failure 2
Limited Case Report Evidence
While one case report described improvement in a patient with diuretic-resistant acute decompensated heart failure after methylprednisolone administration (with increased urine output from baseline to 5.8 L/day and 7 kg weight loss), this represents only anecdotal evidence insufficient to change practice guidelines. 3 Another case report documented reversible heart failure specifically due to primary adrenal insufficiency, where hydrocortisone replacement was treating the underlying endocrine disorder rather than the heart failure itself. 4
The Only Legitimate Indication
Hydrocortisone should only be administered to heart failure patients when treating confirmed adrenal insufficiency (primary or secondary), where it serves as hormone replacement therapy rather than heart failure treatment. 4 In this specific scenario, the patient has an endocrine disorder causing or contributing to cardiac dysfunction, and hydrocortisone addresses the root cause.
Critical Pitfalls to Avoid
- Do not use corticosteroids to enhance diuresis in standard diuretic-resistant heart failure—instead, escalate loop diuretic dosing, add thiazide diuretics for sequential nephron blockade, or add mineralocorticoid receptor antagonists 1, 5, 6
- Do not confuse inflammation with infection—if signs of significant inflammation exist, investigate for underlying causes (myocarditis, pericarditis) that may require specific treatment, but corticosteroids are not part of standard acute heart failure management 1
- Recognize that fluid retention from corticosteroids directly contradicts the primary goal of achieving euvolemia in acute decompensated heart failure 2, 7, 8