Management of Acute Decompensated Heart Failure in Hospitalized Patients
Journal of Clinical Outcomes Management. 2015 April;22(4)
References
Hospitalized patients with ADHF are at increased risk of venous thromboembolism mainly due to reduced cardiac output, increased systemic venous pressure, and reduced activity levels. Therefore, it is recommended that during the hospitalization ADHF patients receive prophylaxis against venous thromboembolism with low-dose unfractionated heparin or low-molecular-weight heparin if there is no contraindication [5].Individual therapeutic choices for ADHF are reviewed in detail below.
What treatments are used to relieve congestion?
Diuresis
In patients admitted to the hospital with ADHF, initial effective diuresis is vital to lowering cardiac filling pressures and relieving symptoms of congestion. Intravenous loop diuretics represent the first line of treatment and have long been the mainstay of therapy for decompensated heart failure with preserved or reduced ejection fraction, reducing fluid overload, and relieving symptoms.
Despite its long track record, the dose administration of IV diuretics is more of an art than a science. Medication dosage sufficient to produce a rate of diuresis that will optimize volume status and relieve signs and symptoms of congestion without causing kidney injury or hypotension is recommended [5].Due to the relatively short half-life of loop diuretics and concerns about tubular sodium reabsorption in the kidneys, continuous IV diuretic infusion has been suggested to enhance diuresis and avoid sodium and fluid rebound [5,20,21]. However, continuous loop diuretic infusion has not proven superior to intermittent IV bolus dosing in clinical studies. Recent data from the Diuretic Optimization Strategies Evaluation (DOSE) trial comparing bolus versus continuous infusion diuretic strategy in patients with ADHF showed no difference in global symptom relief, diuresis, or any of the clinical secondary endpoints including composite of death, re-hospitalization, or ED visits with either IV bolus versus continuous infusion or low versus high doses of furosemide [22]. Concern has also been previously raised about adverse outcomes utilizing high doses of loop diuretics in the treatment of ADHF [20,23,24]. However, the DOSE trial also evaluated the safety of 2 strategies for furosemide dosing in patients with ADHF. The study randomized ADHF patients with a prior diagnosis of chronic heart failure to 4 different treatment groups, either a high dose (2.5x their daily chronic oral furosemide dose) or low dose (1x their daily chronic oral furosemide dose), which was given either twice daily via IV bolus or via continuous infusion. The study showed no difference in change in renal function from baseline to 72 hours with either IV bolus versus continuous infusion or low versus high doses of furosemide [22].
One protocol which seems reasonable is to first give an IV dose of a loop diuretic twice that of the home oral dose and reassess in 1 to 2 hours for response; if there is no response to the initial dose, the loop diuretic should be increased until adequate diuresis occurs or the maximum recommended dose is reached. In patients who fail to respond to large doses of loop diuretics, the addition of a non-loop diuretic (ie, thiazide or potassium-sparing diuretic) may be effective in enhancing the response to the loop diuretic. If the desired clinical response is not achieved, professional guidelines also recommend alternating either a bolus or continuous infusion therapy different from the initial strategy, or other loop diuretic may be considered ( Table 4
