Management of HFrEF Patients Presenting with Sepsis

Acute Sepsis Management in HFrEF

The American College of Cardiology recommends continuing guideline-directed medical therapy (GDMT) in patients with HFrEF who develop sepsis, in the absence of hemodynamic instability or contraindications, while simultaneously implementing aggressive fluid resuscitation targeting adequate tissue perfusion 1
Target adequate tissue perfusion as the principal endpoint rather than arbitrary blood pressure goals, using clinical variables including mental status, capillary refill, urine output, and lactate clearance 2
Infuse fluids aggressively with more than 4 liters potentially required during the first 24-48 hours in adult septic patients, continuing liberal infusions as needed 2

Continue GDMT including ACE inhibitors/ARBs and beta-blockers during septic episodes in most patients, unless hemodynamic instability or specific contraindications exist, as recommended by the American College of Cardiology and the Journal of the American College of Cardiology 1, 3
SGLT2 inhibitors and mineralocorticoid receptor antagonists should generally be continued as they have minimal blood pressure effects and provide ongoing benefit, according to the European Journal of Heart Failure 4, 5

Invasive hemodynamic monitoring should be performed in patients with respiratory distress or impaired perfusion when adequacy of intracardiac filling pressures cannot be determined from clinical assessment, as recommended by the Journal of the American College of Cardiology 3
Monitor for signs of fluid overload including pulmonary edema using bedside thoracic ultrasound for interstitial edema when available, according to the European Heart Journal 7

Transition from intravenous to oral diuretic therapy with careful attention to dosing and monitoring of electrolytes once hemodynamic stability is achieved, as recommended by the Journal of the American College of Cardiology 3
Resume or initiate beta-blocker therapy after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotropic agents, starting at low doses only in stable patients, according to the American College of Cardiology and the Journal of the American College of Cardiology 1, 3