Heart Failure [ACCF/AHA]

Treatment The Hospitalized Patient (see Table 23) Precipitating Causes of Decompensated HF ÎÎACS precipitating acute HF decompensation should be promptly identified by ECG and serum biomarkers, including cardiac troponin testing, and treated optimally as appropriate to the overall condition and prognosis of the patient. (I-C) ÎÎCommon precipitating factors for acute HF should be considered during initial evaluation, as recognition of these conditions is critical to guide appropriate therapy. (I-C) Maintenance of GDMT During Hospitalization ÎÎIn patients with HFrEF experiencing a symptomatic exacerbation of HF requiring hospitalization during chronic maintenance treatment with GDMT, it is recommended that GDMT be continued in the absence of hemodynamic instability or contraindications. (I-B) ÎÎInitiation of beta-blocker therapy is recommended after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotropic agents. Beta-blocker therapy should be initiated at a low dose and only in stable patients. Caution should be used when initiating the use of beta blockers in patients who have required inotropes during their hospital course. (I-B) Diuretics in Hospitalized Patients: Recommendations ÎÎPatients with HF admitted with evidence of significant fluid overload should be promptly treated with intravenous loop diuretics to reduce morbidity. (I-B) ÎÎIf patients are already receiving loop diuretic therapy, the initial intravenous dose should equal or exceed their chronic oral daily dose and should be given as either intermittent boluses or continuous infusion. Urine output and signs and symptoms of congestion should be serially assessed, and the diuretic dose should be adjusted accordingly to relieve symptoms, reduce volume excess, and avoid hypotension. (I-B) ÎÎThe effect of HF treatment should be monitored with careful measurement of fluid intake and output, vital signs, body weight that is determined at the same time each day, and clinical signs and symptoms of systemic perfusion and congestion. Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of intravenous diuretics or active titration of HF medications. (I-C) ÎÎWhen diuresis is inadequate to relieve symptoms, it is reasonable to intensify the diuretic regimen using either: a. Higher doses of intravenous loop diuretics (IIa-B), or b. Addition of a second (eg, thiazide) diuretic (IIa-B). ÎÎLow-dose dopamine infusion may be considered in addition to loop diuretic therapy to improve diuresis and better preserve renal function and renal blood flow. (IIb-B) 40

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