From the Guidelines
For patients with decompensated heart failure exacerbation, the goal for discharge is typically a net negative fluid balance of 1-2 liters, resolution of symptoms, and hemodynamic stability, as recommended by the 2013 ACCF/AHA guideline for the management of heart failure 1, 2.
Key Considerations
- Patients should demonstrate the ability to maintain their fluid status with oral diuretics, usually furosemide 40-80mg once or twice daily, or an equivalent dose of torsemide or bumetanide if furosemide response is inadequate.
- Before discharge, patients should have stable vital signs for at least 24 hours, including systolic blood pressure >90 mmHg, heart rate <100 beats per minute, and oxygen saturation >92% on room air.
- Weight should be stable or decreasing on oral diuretics alone.
- Renal function and electrolytes should be monitored and stabilized, with particular attention to potassium, sodium, and creatinine levels.
- Patients should be transitioned to guideline-directed medical therapy including ACE inhibitors/ARBs/ARNI, beta-blockers, and mineralocorticoid receptor antagonists as tolerated.
Diuretic Therapy
- The initial parenteral dose of loop diuretics should be greater than or equal to the chronic oral daily dose, and then serially adjusted as needed 1, 2.
- When diuresis is inadequate, it is reasonable to give higher doses of intravenous loop diuretics or add a second diuretic, such as a thiazide 1, 2.
Monitoring and Follow-up
- Close follow-up within 7-14 days of discharge is essential to reassess volume status and medication tolerance.
- Patients should be educated on self-monitoring of their volume status, including daily weight measurements and recognition of signs and symptoms of congestion.
- The ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 also emphasize the importance of using the minimum dose necessary to maintain euvolaemia and adjusting the diuretic dose according to the patient's volume status 3.
From the Research
Guideline for Goal In/Out Net for Decompensated Heart Failure Exacerbation
- The primary goal in managing decompensated heart failure is to decrease congestion, afterload, and neurohormonal activation to improve hemodynamics and symptoms, and reduce in-hospital events, re-hospitalizations, and mortality 4.
- Relief of congestion through intravenous loop diuretics is a mainstay of therapy, and ultrafiltration may be used in cases where diuretics are not effective to achieve euvolemia 4.
- Beta-blockers should be continued or reduced in dose at admission, but not typically held, while afterload reduction with vasodilators should be instituted at presentation in patients with normotensive or hypertensive heart failure 4.
- The choice of a particular agent, such as nitroglycerin, nitroprusside, or nesiritide, depends on patient characteristics, including the presence of ischemia, degree of congestion, and renal function 4.
Medication Management
- Sacubitril/valsartan, an angiotensin receptor neprilysin inhibitor (ARNI), has been shown to be superior to angiotensin-converting enzyme (ACE) inhibitors for improving prognosis in patients with heart failure, and is included in clinical practice guidelines for the management of heart failure with reduced ejection fraction (EF) 5, 6.
- The use of ARNIs, such as sacubitril/valsartan, has been increasing over time, and patients receiving ARNIs tend to be younger with fewer comorbidities, but worse ejection fraction 6.
- There is no significant difference in the rate of ARNI use by race and ethnicity, suggesting that ARNIs may be an effective treatment option for patients with heart failure regardless of racial background 6.
Nursing Management
- Nurses play a crucial role in supporting patients with heart failure, and understanding the pathophysiology of the disease is essential for providing effective care 7.
- Nursing interventions, such as monitoring symptoms and adjusting medications, can help alleviate symptoms and deter the advancement of the disease, ultimately reducing morbidity and mortality and optimizing quality of life for patients with heart failure 7.