#469 Inpatient Heart Failure

February 3, 2025 | By Monee Amin

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Video

Transcript available via YouTube

Diuresing ‘til the heart’s content

Master inpatient heart failure management! Learn key tips for initiating guideline-directed medical therapy, diuretic therapy pearls, and ensuring smooth transitions of care. We are joined by Dr. Gurusher Panjrath @PanjrathG (GW School of Medicine and Health Sciences-Dr. Panjrath)

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Show Segments

• Intro
• Rapid Fire Questions/Picks of the Week
• Case Aliquot 1
• Defining Heart Failure
• POCUS in Heart Failure
• Timing/Indications for Echocardiography
• Initiating Diuretic Therapy
• Adjusting Diuretic Therapy/Drip vs Bolus
• Adjunct Diuretic Therapy
• Afterload Reduction
• Monitoring Diuretic Response
• Inpatient Sodium and Fluid Restriction
• Case Aliquot 2
• Classifying Heart Failure
• Pharmacotherapy for HFrEF
• Pharmacotherapy for HFpEF
• Ischemic Evaluation
• Interval Summary/Highlights
• Case Aliquot 3
• Considerations for Initial Care of Cardiogenic Shock
• Choosing Inotrope/Vasopressor
• Right Heart Catheterization
• Case Aliquot 4
• Discharge Medications for Heart Failure
• Titration of Goal Directed Medical Therapy
• Post Discharge Follow Up
• Washout Period for ACEi/ARB
• Cost/Barriers of ARNI
• Patient Education
• Take Home Points
• Outro

Inpatient Heart Failure Pearls

1. Go back to the basics and ask yourself, “Does this patient have heart failure?” Watch out for mimics of heart failure.
2. Reducing afterload can augment diuretic output in patients with volume overload.
3. All patients suspected of having heart failure without a known diagnosis should undergo a transthoracic echocardiogram. Additionally, patients with a known diagnosis do not need routine repeat echo without a specific question that will change management.
4. The four pillars of guideline-directed medical therapy (GDMT) for HFrEF are beta blockers, SGLT2 inhibitors, ARB/ARNIs, and aldosterone antagonists.  
5. Low doses of all components of GDMT is better than high doses of only a few.

Inpatient Heart Failure 

Definitions

Heart failure is a complex clinical syndrome with signs and symptoms that result from any structural or functional impairment of ventricular filling or ejection of blood (Heidenrich, 2022). 

However, not all that causes leg swelling and shortness of breath is heart failure. Consider a patient’s risk factors when you suspect heart failure, and be aware of heart failure mimics. 

Heart failure with reduced ejection fraction (HFrEF) is defined as an ejection fraction less than 40%,  while heart failure preserved ejection fraction (HFpEF) is defined by an ejection fraction above 50%. Those patients with an EF of 41-49% are considered to have HFmrEF (heart failure with mid range EF) (Heidenrich, 2022). 

Evaluations of Patients with Heart Failure

Echocardiography in Heart Failure 

Patients presenting with signs and symptoms suggestive of heart failure but without a previously established diagnosis require evaluation with echocardiography (Heidenrich, 2022). Echocardiography guides initial CHF management because it determines whether therapies for HFrEF or HFpEF are indicated. Additionally, echocardiography can identify useful anatomical features (e.g. valvulopathy, wall motion abnormalities, wall thickness) that may impact therapy or workup.

Patients with a known diagnosis of heart failure and a recent echocardiogram do not all need routine echocardiography during the acute decompensation (Harrison, 2023). Lack of response to initial treatment or a new finding on history or exam (e.g. a new murmur) should prompt repeat evaluation (Heidenrich, 2022). 

Ischemic Evaluation 

Consider inpatient ischemic evaluation in patients with a high pretest probability of coronary artery disease (CAD).  Logistical considerations may also prompt an inpatient ischemic evaluation (e.g. social determinants of health) (expert opinion).

Dr. Panjrath routinely does inpatient ischemic evaluations for patients with risk factors (expert opinion) but notes it is reasonable to complete as an outpatient if risk factors are minimal or there are barriers that arise in setting of acute decompensated heart failure (e.g. renal dysfunction, ability to lay flat and participate in testing). In addition, left heart catheterization is not always required: cardiac CTA or stress testing may be an option, depending on the individual patient.  

POCUS in Heart Failure

Dr. Panjrath notes point-of-care ultrasound (POCUS) has an emerging role in heart failure. POCUS can provide real-time assessment of ejection fraction, valvular function, and volume status. Obtaining this information at the bedside may facilitate early management decisions. 

Management of Acutely Decompensated Heart Failure 

Diuresis

The first step in treating acute decompensated heart failure is decongestion with diuretic therapy. Dr. Panjrath suggests monitoring electrolytes and renal function and using this information to guide dosing decisions. 

Afterload reduction can be helpful in augmenting diuresis – in particular, vasodilators may alleviate symptoms and improve diuresis if a patient’s blood pressure tolerate them. If a patient has signs of hypoperfusion, escalation of care and other modalities may be required (Heidenreich, 2022). 

For diuretic-naive patients, it is reasonable to start with a low dose bolus (20mg or 40mg) of IV furosemide and gauge response in two hours (expert opinion). If the patient is not responding, then the dose should be increased. Diuretic therapy can be administered by bolus as much as three to four times per day to achieve adequate response (expert opinion); however, patient comfort may impact this decision. 

For patients already on diuretics, higher doses or adjunct diuretics may be necessary (Heidenreich, 2022). An example would be starting the IV equivalent of the outpatient dose or doubling it. Consider switching to torsemide or bumetanide in patients who require large doses of IV furosemide without adequate response. Adjunct diuretic therapies may be necessary in patients with diuretic resistance (Heidenreich, 2022). Sequential nephron blockade with thiazide diuretics, including chlorothiazide and metolazone, has been studied (Moranville, 2015). SGLT2 inhibitors also have diuretic activity and can be added early on to augment diuretic effect if renal function allows (expert opinion). Acetazolamide is another option for adjunct diuretic therapy, but Dr. Panjrath favors SGLT2 inhibitors first, as they are part of GDMT and have demonstrated morbidity benefits in CHF (Heidenreich, 2022).

In patients who are not responding to maximal bolus diuretic therapy, Dr. Panjrath recommends a continuous infusion, or drip (expert opinion). He notes that the DOSE trial, which compared bolus vs continuous infusion of diuretics and did not show any differences in symptoms or change in creatinine level for the modality used, did suggest that patients treated with a high-dose diuretics had greater relief of dyspnea and greater urine output without lasting impairment in renal function (Felker, 2011). In his experience, Dr. Panjrath notes that drips are a safe and effective way to decongest patients faster, with a total higher dose. (expert opinion).  

Monitoring Diuretic Response

Accurate intake and outputs and daily weights (taken at the same time every day) are helpful to assess diuretic efficacy (Heidenreich, 2022). Dr. Panjrath reminds us that malnutrition can also lead to weight fluctuation, and to be mindful of this for the patients with prolonged hospitalizations. 

Dr. Panjrath feels it may be reasonable in certain situations (for example, severe hyponatremia) to restrict fluid, and his practice is a 48-64 oz (1.5-2L) fluid restriction. He does not use strict sodium restriction in the hospital as it may hamper nutrition, other than a general limit of 2 gm per day.

The Decompensating Heart Failure Patient

If a patient progresses to cardiogenic shock, stop any drugs that can lower the blood pressure. Otherwise, the next best step in management would be to escalate care rapidly and utilize institutional resources for shock management.

The guidelines state that there is not clear data suggesting use of one vasopressor over another.  Instead, choice of pressor should be guided by the clinical status of the patient  (Heidenreich, 2022). Dr. Panjrath notes that if the patient is very hypotensive, norepinephrine should be considered. Otherwise, inotropic agents like milrinone and dobutamine may be used.

In selected patients who are not responding to therapy or who clinically worsen despite adequate therapy, further diagnostics should be considered, such as right heart catheterization. (Heidenreich, 2022).  

Guideline Directed Medical Therapy for Heart Failure

Therapies for HFrEF

The four pillars of guideline-directed medical therapy (GDMT) are beta blockers, SGLT2 inhibitors, ARB/ARNIs, and aldosterone antagonists.  The sequence of adding them will vary based on the clinical picture during acute hospitalization (e.g., BP, renal function). SGLT2 inhibitors are recommended early during therapy due to their augmentation of diuresis. Dr. Panjrath notes there is an overall lack of data on inpatient management with aldosterone antagonists, but consider starting one if patients are hypokalemic during diuresis. He cautions not to start a beta blocker on the day of discharge and instead start it at least 24 hours before discharge to allow adequate monitoring. Because hypotension is a common side effect or ARNIs, (more so than with the other classes), patients should be decongested first prior to adding an ARNI.

Therapies for HFpEF

SGLT2 inhibitors are useful in all genders and across all ejection fractions. ARNIs may be useful for women and all EFs, but men may see the biggest benefit with EF <60%. Aldosterone antagonists have a grade IIa recommendation for reducing hospitalization and improving diuresis (Heidenreich, 2022). Beta blockers have no role in HFpEF unless there is another primary indication for beta blockade such as arrhythmia or CAD. 

Preparing for discharge

When preparing for discharge, recent literature supports rapid up-titration of GDMT (Mebazaa, 2022). For the hospitalist, this raises the question: is it better to prioritize starting all four pillars, or to achieve maximal therapy with single pillars first? Dr. Panjrath recommends starting low doses of all four pillars first, as this may be better tolerated, and further uptitration can occur in the outpatient setting. Follow up should occur within 1 week (Heidenreich, 2022). Patient education is also an important part of the transition of care process, and should include explaining medications, side effects, and expected follow-up plans.

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Goal

Listeners will learn the latest evidence-based practice to manage patients hospitalized with acute decompensated heart failure (ADHF).

Learning objectives

After listening to this episode listeners will…  

1. Define common terms: Heart failure with preserved ejection fraction (HFpEF), heart failure with reduced ejection fraction (HfrEF), and acute decompensated heart failure (ADHF)
2. Review strategies for diuresis in patients hospitalized for heart failure
3. List any pharmacologic options that have demonstrated mortality benefit in heart failure 
4. Be able to manage beta blocker therapy during ADHF
5. Establish a framework to recognize when a patient should be evaluated for ischemia, initiation of inotropes, or right heart catheterization (RHC)
6. Discuss important aspects of discharge planning and transition of care to the clinic

Disclosures

Dr. Panjrath reports an Honoraria with Pfizer and CVRx. The Curbsiders report no relevant financial disclosures. 

Citation

Blackburn, R., Amin, M., Trubitt, M., Coleman, C. Panjrath, G., “#469 Inpatient Heart Failure”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast February 3rd, 2025.