Acute decompensated heart failure management
In a patient hospitalized with HF who has evidence of significant fluid overload, intravenous loop diuretics are recommended promptly to improve symptoms and reduce morbidity (Class I, Level of Evidence B-NR) [1]. Decongestion should be titrated to resolve clinical evidence of congestion to reduce symptoms and rehospitalizations (Class I, Level of Evidence B-NR) [1].
Initial assessment and triage
The severity of congestion and adequacy of perfusion should be assessed to guide triage and initial therapy (Class I, Level of Evidence C-LD) [1]. Common precipitating factors should be assessed to guide appropriate therapy (Class I, Level of Evidence C-LD) [1].
Primary acute therapy: intravenous loop diuretics
Intravenous loop diuretics should be initiated promptly in the presence of significant fluid overload to improve symptoms and reduce morbidity (Class I, Level of Evidence B-NR) [1]. Diuretic therapy and other guideline-directed medications should be titrated with a goal to resolve clinical evidence of congestion (Class I, Level of Evidence B-NR) [1].
Escalation when inadequate decongestion occurs
When diuresis is inadequate to relieve symptoms and signs of congestion, intensification of the diuretic regimen is reasonable using either higher doses of intravenous loop diuretics or addition of a second diuretic (Class IIa, Level of Evidence B-NR) [1]. Addition of a thiazide (for example, metolazone) to a loop diuretic should be reserved for patients who do not respond to moderate- or high-dose loop diuretics to minimize electrolyte abnormalities (Class IIa, Level of Evidence B-NR) [1].
Parenteral vasodilator adjunct for dyspnea
In patients admitted with decompensated HF, in the absence of systemic hypotension, intravenous nitroglycerin or nitroprusside may be considered as an adjuvant to diuretic therapy for relief of dyspnea (Class IIb, Level of Evidence B-NR) [1].
Decongestion goals during hospitalization
Clinical monitoring should target resolution of signs and symptoms of congestion, rather than achieving a specific natriuretic-peptide threshold (Class I, Level of Evidence B-NR) [1]. Diuretic and guideline-directed therapy should be titrated during hospitalization to reduce symptoms and rehospitalizations (Class I, Level of Evidence B-NR) [1].
Treatment continuation and inpatient GDMT timing
In patients with HFrEF requiring hospitalization, preexisting guideline-directed medical therapy should be continued and optimized unless contraindicated (Class I, Level of Evidence B-NR) [1]. In HFrEF, guideline-directed medical therapy should be initiated during hospitalization after clinical stability is achieved (Class I, Level of Evidence B-NR) [1].
Common management errors to avoid
Thiazide-type diuretic addition should not be used as an early step for all patients with insufficient response to loop diuretics, because reserved use for patients not responding to moderate- or high-dose loop diuretics is recommended to minimize electrolyte abnormalities (Class IIa, Level of Evidence B-NR) [1].
Therapy planning at discharge
For patients requiring diuretic treatment during hospitalization, the discharge regimen should include a plan for adjustment of diuretics to decrease rehospitalizations (Class IIa, Level of Evidence B-NR) [1].