CHF exacerbation is acute decompensated heart failure until proven otherwise: confirm congestion, identify the trigger, determine whether the patient is warm or cold, diurese aggressively when congested, escalate early if hypoperfusing, and start/optimize GDMT before discharge once stable.
Definitions
HFrEF
LVEF ≤40%
Main disease-modifying therapies are the 4 pillars of GDMT: ARNI/ACEi/ARB, beta blocker, MRA, and SGLT2 inhibitor.
HFmrEF
LVEF 41-49%
Treat congestion similarly. SGLT2 inhibitors have the strongest evidence; consider HFrEF-type therapies when appropriate.
HFpEF
LVEF ≥50%
Focus on decongestion, BP control, SGLT2 inhibitor, comorbidity management, rhythm control when relevant, and selected MRA/ARNI use.
Not all dyspnea + edema is heart failure. Consider COPD/asthma, PE, pneumonia, ACS, renal failure, cirrhosis, nephrotic syndrome, venous insufficiency, medication edema, anemia, obesity/deconditioning, and lymphedema.
Initial bedside question
1
Is the patient congested?
JVD, orthopnea, edema, pulmonary edema, pleural effusions, ascites, weight gain, elevated BNP/NT-proBNP, dilated IVC, B-lines, or elevated filling pressures.
2
Is the patient perfusing?
Warm extremities, normal mentation, adequate urine output, stable lactate, stable renal/liver function, and no progressive hypotension.
3
What triggered this?
Diet/med nonadherence, uncontrolled HTN, ACS, arrhythmia, infection, PE, worsening renal function, valvular disease, alcohol/drugs, NSAIDs, steroids, TZDs, non-DHP CCBs, chemotherapy, or progression of HF.
| Profile | Finding | Typical approach |
|---|---|---|
| Warm + wet | Congested, perfusing | IV loop diuresis, treat trigger, optimize GDMT |
| Cold + wet | Congested + hypoperfusing | Escalate care, IV diuresis if BP allows, consider inotrope/RHC |
| Cold + dry | Hypoperfusing without clear congestion | Reassess diagnosis/volume status, consider RHC, cautious fluids only if truly underfilled |
| Warm + dry | Compensated | Look for non-HF cause of symptoms |
Evaluation
Core workup
- Vitals, oxygen requirement, weight, strict I/Os, exam for JVD/edema/perfusion
- ECG, chest X-ray, BMP/Mg, CBC, LFTs, BNP/NT-proBNP, troponin if concern for ischemia or myocardial injury
- Identify trigger: infection, ACS, arrhythmia, hypertensive emergency, renal failure, PE, med/diet nonadherence
- Review home diuretic dose, last known dry weight, last echo, baseline Cr, and prior admissions
Echocardiography
Get an echo if new HF, unknown EF, no recent echo, new murmur, suspected valvular disease, concern for new cardiomyopathy, new wall motion abnormality, or clinical course is not matching known history.
Repeat echo is not mandatory for every decompensation if a recent high-quality echo exists and there is no new clinical change.
Ischemic evaluation
- Consider inpatient evaluation if ACS concern, new HFrEF, high-risk features, refractory symptoms, ventricular arrhythmia, or significant troponin rise with concerning clinical picture
- Low-risk or clearly triggered decompensation may be reasonable for outpatient ischemic evaluation
- Testing options include coronary angiography, coronary CTA, stress imaging, or medical management depending on risk, renal function, and candidacy for revascularization
POCUS
POCUS is useful for rapid bedside pattern recognition: LV function, RV size/function, pericardial effusion, gross valvular disease, IVC size/collapsibility, B-lines, and pleural effusions.
Initial management of acute decompensated HF
1. Decongest
IV loop diuretic is first-line for volume overload. Dose based on home loop exposure and renal function.
2. Treat trigger
Control BP, manage arrhythmia, treat infection, evaluate ischemia, stop offending meds, address renal failure.
3. Start GDMT
Once stable, prioritize low doses of multiple disease-modifying therapies rather than maxing one drug.
Do not reflexively keep pushing diuretics in shock. If hypotension, rising lactate, oliguria, altered mentation, cool extremities, or worsening end-organ function develops, reassess perfusion and escalate care.
Loop diuretics
Starting dose
- Diuretic-naive: furosemide 20-40 mg IV, then reassess response
- On chronic loop: start at home total daily oral dose converted to IV, often 1-2.5x depending on severity
- Severe congestion or CKD: higher initial IV dosing is often needed
- Reassess early: urine output and/or spot urine sodium within 2-6 hours
| Loop | Common PO dose | Common IV dose | Approx equivalent | Clinical note |
|---|---|---|---|---|
| Furosemide | 40 mg PO | 20 mg IV | Baseline | Variable oral absorption, especially with gut edema |
| Torsemide | 20 mg PO | Not commonly used IV | ≈ furosemide 40 mg PO | Better bioavailability and longer half-life than furosemide |
| Bumetanide | 1 mg PO | 1 mg IV | ≈ furosemide 40 mg PO or 20 mg IV | More predictable absorption; useful when poor response to furosemide |
Response targets
| Metric | Good response | Poor response |
|---|---|---|
| Urine output | Meaningful output within 2-6 hours | Minimal UOP after adequate IV loop dose |
| Net fluid balance | Often goal net -1 to -2 L/day, more if severe congestion and tolerated | Persistently net even/positive despite escalating loop |
| Weight | Daily decline toward dry weight | No change despite documented intake/output |
| Labs | Stable electrolytes and renal function or mild acceptable Cr change with decongestion | Severe hypoK/hypoMg, progressive AKI with poor decongestion, rising lactate |
A small creatinine rise during effective decongestion is common. Do not stop diuresis automatically if the patient remains clearly congested and perfusing.
Diuretic resistance
First check the basics
- Is the dose high enough for renal function and home loop exposure?
- Is the patient actually receiving meds and following fluid/sodium restriction?
- Are I/Os accurate?
- Is there ongoing NSAID use, severe CKD, gut edema, low albumin, or cardiorenal syndrome?
- Is this actually congestion, or is dyspnea from another process?
Escalation options
| Strategy | Typical use | Common dose | Watch |
|---|---|---|---|
| Increase loop dose | First step if poor response | Double IV loop dose and reassess | K, Mg, Cr, BP |
| Increase frequency | Short duration of response | BID/TID IV dosing | Electrolytes, overdiuresis |
| Continuous infusion | Refractory congestion or large loop requirements | Institution-specific, usually after IV bolus | Hypotension, electrolytes |
| Metolazone | Sequential nephron blockade | 2.5-5 mg PO | HypoNa, hypoK, AKI |
| Chlorothiazide | IV thiazide when gut absorption is unreliable | 250-500 mg IV | HypoNa, hypoK, AKI |
| Acetazolamide | Adjunct in volume overload, especially early decongestion strategy | 500 mg IV daily | Bicarb, renal function, acid-base status |
| SGLT2 inhibitor | Early inpatient initiation once stable and no contraindication | Empagliflozin 10 mg daily or dapagliflozin 10 mg daily | eGFR, ketoacidosis risk, active fasting/critical illness |
Thiazide add-on works, but it is not benign. Check BMP/Mg at least daily, often BID with aggressive sequential nephron blockade.
The decompensating HF patient
Concerning features
SBP persistently low
cool extremities
altered mentation
oliguria
rising lactate
worsening Cr/LFTs
narrow pulse pressure
escalating oxygen/pressors
Cardiogenic shock = hypoperfusion from cardiac dysfunction. Stop BP-lowering meds, call for help early, consider ICU/CCU transfer, and consider invasive hemodynamics when the phenotype is unclear or response is poor.
Vasopressors and inotropes
| Medication | Best fit | Typical dose | Main downside |
|---|---|---|---|
| Norepinephrine | Hypotension with shock physiology | Titrate to MAP/perfusion | Afterload increase, arrhythmia risk |
| Dobutamine | Low-output state, low BP, need for inotropy | 2-20 mcg/kg/min | Tachycardia, arrhythmias, ischemia |
| Milrinone | Low-output state with high SVR, RV dysfunction, pulmonary HTN, beta-blocked patient | 0.125-0.75 mcg/kg/min, avoid loading dose in unstable patients | Hypotension, arrhythmias, renal accumulation |
When to consider right heart cath
- Shock or suspected shock with unclear filling pressures
- Poor response to escalating diuresis
- Cardiorenal syndrome with uncertainty about congestion vs underfilling
- Concern for severe pulmonary HTN or RV failure
- Advanced HF, transplant/LVAD evaluation, or mechanical circulatory support consideration
GDMT during admission
HFrEF: 4 pillars
| Class | Examples | Start when | Hold/avoid when |
|---|---|---|---|
| ARNI / ACEi / ARB | Sacubitril-valsartan, valsartan, lisinopril | BP stable, renal function acceptable, not in shock | Hypotension, severe AKI, hyperK, angioedema history for ACEi/ARNI |
| Evidence beta blocker | Metoprolol succinate, carvedilol, bisoprolol | Euvolemic or improving, warm, no shock | Shock, severe bradycardia, high-grade AV block, severe active bronchospasm |
| MRA | Spironolactone, eplerenone | K and renal function acceptable | HyperK, severe renal dysfunction |
| SGLT2 inhibitor | Empagliflozin, dapagliflozin | Often early once stable and not critically ill | DKA risk, prolonged fasting, severe acute illness, very low eGFR depending on indication |
Discharge principle: low doses of all indicated pillars are usually better than a high dose of one medication while missing the others.
HFpEF
- Decongest with diuretics when volume overloaded
- Start SGLT2 inhibitor unless contraindicated
- Control BP aggressively
- Manage AF, CAD, obesity, OSA, CKD, diabetes, and pulmonary HTN contributors
- Consider MRA in selected patients with elevated BNP or EF closer to 50%
- Consider ARNI in selected patients, especially EF below normal range
- Beta blockers are not routine HFpEF therapy unless needed for AF, CAD, angina, prior MI, or rate control
Discharge checklist
| Item | Goal before discharge |
|---|---|
| Volume status | Near euvolemic, stable oxygen requirement, improving edema/JVD, stable weight trend |
| Oral diuretic plan | Effective PO loop dose with clear instructions and contingency plan |
| Electrolytes/renal function | Stable BMP/Mg on discharge regimen |
| GDMT | Start all indicated tolerated therapies before discharge; document why any are deferred |
| Follow-up | HF/cardiology or PCP follow-up ideally within 7 days, earlier if high risk |
| Patient education | Daily weights, low-sodium diet, medication adherence, red flags, when to call |
| Labs | Repeat BMP/Mg after discharge, especially after diuretic or GDMT changes |
Practical discharge language: call if weight increases by 2-3 lb in 24 hours or 5 lb in a week, worsening dyspnea, orthopnea, edema, dizziness/syncope, or inability to take medications.
Primary resources
- Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure. Circulation. 2022.
- Kittleson MM, Panjrath GS, Amancherla K, et al. 2023 ACC expert consensus decision pathway on management of heart failure with preserved ejection fraction. J Am Coll Cardiol. 2023.
- Felker GM, Lee KL, Bull DA, et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med. 2011.
- Mullens W, Dauw J, Martens P, et al. Acetazolamide in acute decompensated heart failure with volume overload. N Engl J Med. 2022.
- Voors AA, Angermann CE, Teerlink JR, et al. The SGLT2 inhibitor empagliflozin in patients hospitalized for acute heart failure. Nat Med. 2022.
- Mebazaa A, Davison B, Chioncel O, et al. Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure. Lancet. 2022.