Management of Congestive Heart Failure Exacerbation

Initial Assessment and Management

The American College of Cardiology recommends performing careful measurement of fluid intake and output, vital signs, daily body weight, and clinical signs of systemic perfusion and congestion for patients with CHF exacerbation 1
The American College of Cardiology suggests monitoring daily serum electrolytes, urea nitrogen, and creatinine during IV diuretic use or active titration of heart failure medications for patients with CHF exacerbation 1, 2
The European Heart Journal recommends administering supplemental oxygen for patients with hypoxemia 3
The European Heart Journal suggests considering non-invasive ventilation (CPAP or BiPAP) for patients with persistent hypoxia and tachypnea despite oxygen therapy, as it improves cardiac hemodynamics, symptoms, and oxygenation 4

The American College of Cardiology recommends starting with IV loop diuretics at doses equal to or exceeding the patient's chronic oral daily dose for patients with CHF exacerbation 1, 2
The American College of Cardiology suggests intensifying the diuretic regimen using one of the following approaches when diuresis is inadequate to relieve congestion: higher doses of loop diuretics, addition of a second diuretic, or continuous infusion of a loop diuretic 1, 2

The American College of Cardiology recommends administering IV inotropic or vasopressor drugs to maintain systemic perfusion and preserve end-organ performance for patients with hypotension associated with hypoperfusion and elevated cardiac filling pressures 1, 2
The American College of Cardiology suggests considering dobutamine as the preferred inotropic agent for patients with low cardiac output and signs of hypoperfusion despite adequate filling, but notes that long-term use of infused positive inotropic drugs is not recommended except as palliation for end-stage disease 5, 6

The American College of Cardiology recommends reconciling medications on admission and discharge, and continuing ACE inhibitors/ARBs and beta-blockers in patients with reduced ejection fraction on chronic maintenance treatment 1, 2
The American College of Cardiology suggests initiating ACE inhibitors/ARBs and beta-blockers in stable patients prior to hospital discharge, and initiating beta-blocker therapy only after optimization of volume status and successful discontinuation of IV diuretics, vasodilators, and inotropic agents 1, 2

The American College of Cardiology recommends using diuretics judiciously to reduce congestion and improve symptoms, and considering SGLT2 inhibitors as disease-modifying therapy based on recent positive clinical trials 7, 8
The American College of Cardiology suggests considering mineralocorticoid receptor antagonists (MRAs) for symptom management in patients with HFpEF 7, 8

The American College of Cardiology recommends providing comprehensive written discharge instructions with emphasis on diet, discharge medications, activity level, follow-up appointments, daily weight monitoring, and instructions on what to do if heart failure symptoms worsen 1, 2, 5
The American College of Cardiology suggests utilizing post-discharge systems of care to facilitate transition to effective outpatient care, and enrolling patients in multidisciplinary heart failure management programs to reduce the risk of hospitalization and improve survival 1, 2, 3, 5