42
The Hospitalized Patient (see Table 25)
Precipitating Causes of Decompensated HF
Î ACS 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)
Î Common 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
Î In 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)
Î Initiation 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
Î Patients with HF admitted with evidence of significant fluid overload
should be promptly treated with intravenous loop diuretics to reduce
morbidity. (I-B)
Î If 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)
Î The 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)
Î When 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).
Î Low-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)
Treatment
