What is the recommended management of pitting edema in a bed‑bound obese patient with chronic heart failure on sacubitril‑valsartan (Entresto) and low‑dose oral furosemide who has intermittent hypotension?

Management of Pitting Edema in a Bed-Bound Obese Patient with Heart Failure on Entresto and Low-Dose Furosemide with Intermittent Hypotension

Increase IV furosemide to at least 40 mg IV (double the current oral dose) and continue aggressive diuresis until all signs of congestion resolve, even if blood pressure drops modestly, as long as systolic BP remains ≥90 mmHg without signs of end-organ hypoperfusion. 1, 2

Initial Assessment and Decision Algorithm

First, determine whether hypotension represents true hypoperfusion or isolated low blood pressure:

• Measure systolic blood pressure and assess for signs of hypoperfusion: cool extremities, altered mental status, oliguria (urine output <0.5 mL/kg/h), elevated lactate, or worsening renal function 1, 2
• If SBP ≥90 mmHg: proceed immediately with IV diuretic escalation regardless of the absolute blood pressure number 1, 2
• If SBP <90 mmHg AND signs of hypoperfusion are present: temporarily hold diuretics, exclude hypovolemia or other reversible causes, and consider short-term inotropic support (dobutamine or milrinone) before resuming diuresis 1, 2

The critical distinction: Mild-to-moderate hypotension without end-organ dysfunction is NOT a contraindication to aggressive diuresis in heart failure. 1, 2

Immediate Diuretic Management

Switch from oral to IV furosemide and escalate the dose:

• Hold the oral furosemide 20 mg and initiate IV furosemide at a dose equal to or exceeding the total daily oral dose—start with at least 40 mg IV as a slow push over 1-2 minutes 1, 2
• Insert a urinary catheter to measure hourly urine output accurately, targeting >0.5 mL/kg/h 1, 2
• If adequate diuresis is not achieved within 2 hours, increase the dose by 20 mg every 2 hours until effective diuresis occurs 2
• Do not exceed 100 mg in the first 6 hours or 240 mg in the first 24 hours 2

Rationale for aggressive diuresis despite hypotension: Persistent congestion in heart failure elevates ventricular wall stress, activates neurohormonal pathways (RAAS, sympathetic nervous system), and impairs renal venous drainage through elevated right atrial pressure—all of which worsen both hypotension and edema in a vicious cycle. 1, 2 Diuresis lowers filling pressures and can actually improve cardiac output by shifting the failing heart toward a more favorable segment of the Frank-Starling curve. 1, 2

Sequential Nephron Blockade for Diuretic Resistance

If adequate diuresis is not achieved after 24-48 hours despite IV furosemide ≥160 mg/day, add a second diuretic class:

• Metolazone 2.5-5 mg PO daily is the preferred agent for potent sequential nephron blockade 1, 2
• Alternative: Hydrochlorothiazide 25 mg PO daily 2
• Spironolactone 25-50 mg PO daily may be added only if serum potassium <5.0 mmol/L and creatinine <2.5 mg/dL 1, 2
• Low-dose combination therapy is more effective with fewer adverse effects than high-dose monotherapy 1, 2

Critical Monitoring Requirements

Hourly during acute phase:

• Urine output via bladder catheter (target >0.5 mL/kg/h) 1, 2
• Blood pressure and signs of hypoperfusion 1, 2
• Respiratory status and oxygen saturation 1

Daily while actively diuresing:

• Body weight at the same time each morning, targeting loss of 0.5-1.0 kg per day 1, 2
• Serum electrolytes (especially potassium); hold furosemide if K+ <3.0 mEq/L 1, 2
• BUN and creatinine; consider holding furosemide if creatinine rises >0.3 mg/dL or exceeds 2.5 mg/dL, or if eGFR falls below 30 mL/min/1.73 m² 2

Management of Entresto During Acute Decompensation

Continue sacubitril/valsartan (Entresto) throughout the acute decompensation unless true hypoperfusion is present (SBP <90 mmHg with end-organ dysfunction):

• Entresto enhances natriuresis and diuresis, improving response to furosemide 3
• Discontinuing Entresto after asymptomatic hypotension is associated with significantly worse outcomes 4
• Symptomatic hypotension is more common with Entresto than with ACE inhibitors, but this does not warrant discontinuation unless accompanied by hypoperfusion 5, 6
• If asymptomatic hypotension occurs, continue Entresto and proceed with diuresis as planned 4

Adjunctive Therapies

If systolic BP >110 mmHg despite congestion:

• Add IV vasodilators (nitroglycerin or nitroprusside) to reduce afterload, improve cardiac output, and facilitate diuresis 1, 2

For respiratory distress or pulmonary edema:

• Provide supplemental oxygen if SpO₂ <90% 1, 2
• Apply non-invasive ventilation (CPAP or BiPAP with PEEP 5-7.5 cm H₂O) for respiratory distress 1, 2

Avoid NSAIDs completely:

• NSAIDs block diuretic effects and worsen renal function 1, 2

Common Pitfalls to Avoid

The most dangerous error is under-utilizing diuretics due to excessive concern about hypotension or azotemia:

• Persistent volume overload not only perpetuates symptoms but also limits the efficacy and compromises the safety of other heart failure medications, including Entresto 1, 2
• Continue diuresis until all clinical evidence of fluid retention is eliminated (no jugular venous distension, no peripheral edema, no pulmonary crackles), even if this results in mild decreases in blood pressure or renal function, as long as the patient remains asymptomatic 1, 2
• Diuresis should be slowed but NOT stopped if hypotension or azotemia develops before treatment goals are achieved 1, 2

Do not discontinue Entresto for isolated low blood pressure readings:

• Asymptomatic hypotension during Entresto therapy does not require drug discontinuation and stopping it worsens prognosis 4
• Only hold Entresto if SBP <90 mmHg with confirmed end-organ hypoperfusion 2

Do not start with inadequate IV furosemide doses:

• Starting with 20-40 mg IV is insufficient for patients already on chronic oral diuretics; the initial IV dose must equal or exceed the total daily oral dose 1, 2

Do not delay combination diuretic therapy when monotherapy fails:

• If maximal recommended IV furosemide doses (160-240 mg/day) fail to produce adequate diuresis, add a thiazide or aldosterone antagonist rather than further increasing the loop diuretic dose 1, 2