Tapering Dopamine and Discharge Planning for Heart Failure Patient with Reduced Ejection Fraction

Assessment and Tapering Protocol

• The European Society of Cardiology recommends that dopamine should be gradually tapered while optimizing oral heart failure medications, with close monitoring of blood pressure and symptoms before discharge, in patients with heart failure with reduced ejection fraction (EF 42%) who are stable on dopamine infusion (4 ml/hr of 5mg/ml) with adequate blood pressure (120/60 mmHg) 1
• The American Heart Association suggests that intravenous furosemide (Dytor) can be discontinued and oral furosemide 10mg TDS can be initiated in patients with heart failure with reduced ejection fraction 2
• The European Society of Cardiology recommends that if blood pressure remains stable (systolic >90 mmHg), dopamine tapering can be continued until complete discontinuation 1

Optimization of Oral Heart Failure Medications

• The American College of Cardiology recommends initiating or optimizing guideline-directed medical therapy (GDMT) for HFrEF, including starting with low doses of beta-blockers (preferably selective β₁ blockers due to lesser BP-lowering effect) 1
• The European Society of Cardiology suggests considering low-dose ACE inhibitor (or ARB if ACE inhibitor contraindicated) or very low-dose sacubitril/valsartan (25-50mg twice daily) in patients with heart failure with reduced ejection fraction 1
• The European Heart Journal recommends adding mineralocorticoid receptor antagonist (MRA) such as spironolactone in patients with heart failure with reduced ejection fraction 4

Diuretic Management and Discharge Planning

• The European Journal of Heart Failure recommends adjusting diuretic dose according to volume status, avoiding overdiuresis which can lead to hypotension 1
• The American Heart Association suggests scheduling follow-up visit within 7-14 days and telephone follow-up within 3 days of discharge, and addressing optimization of chronic oral HF therapy with clear medication plan, assessment of volume status and blood pressure, monitoring of renal function and electrolytes, and patient education on heart failure self-management 2

Monitoring Parameters

• The European Journal of Heart Failure recommends daily monitoring of vital signs including blood pressure, heart rate, and weight, as well as regular monitoring of renal function and electrolytes during medication adjustments 1
• The American College of Cardiology suggests monitoring daily assessment of symptoms (dyspnea, orthopnea, edema) and signs of worsening heart failure requiring immediate attention (increasing dyspnea, edema, weight gain) 3

Special Considerations

• The European Journal of Heart Failure recommends prioritizing beta-blockers over vasodilators if the patient develops symptomatic hypotension during medication titration 1
• The European Journal of Heart Failure suggests considering ivabradine as an alternative to beta-blockers if heart rate remains elevated (>70 bpm) despite hypotension 1