Bedside Rounds

Acute decompensated heart failure: workup and management

Acute decompensated heart failure. Classify by congestion and perfusion (warm/cold, wet/dry), find the precipitant, decongest with IV loop diuretics, and keep guideline-directed medical therapy going where possible.

Working diagnosis Adult · US guidelines Draft · awaiting physician review
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01Orient

What's new in the evidence

  • DICTATE-AHF (2024): starting dapagliflozin early in the admission improved diuretic efficiency; start an SGLT2 inhibitor in hospital once stable
  • PUSH-AHF (2023): natriuresis-guided diuretic titration increased sodium excretion; a spot urine sodium <50–70 mEq/L at 2 hours flags an inadequate response
  • STRONG-HF (2022): rapid up-titration of GDMT before and within 6 weeks after discharge reduced death or HF readmission
  • FINEARTS-HF (2024): finerenone reduced worsening HF events with LVEF ≥40%
  • ADVOR (2022): acetazolamide added to loop diuretics improved decongestion

Differential diagnoses

  1. Precipitant: ACS, arrhythmia (AF), uncontrolled hypertension
  2. Precipitant: medication or diet non-adherence, NSAIDs, negative inotropes
  3. Precipitant: infection, anemia, thyroid disease
  4. Valve disease (acute MR, aortic stenosis)
  5. Mimics: COPD, pneumonia, PE, nephrotic syndrome, cirrhosis

02Assess

Risk scores and decision tools

  • Hemodynamic profile: warm/cold and wet/dry
  • Spot urine sodium 2 hours after loop diuretic (<50–70 mEq/L = escalate)
  • GWTG-HF in-hospital mortality risk score
  • NT-proBNP trajectory before discharge

Key history questions

  • Dyspnea, orthopnea, PND, weight gain, edema
  • Diuretic dose and adherence; salt and fluid intake
  • Recent NSAIDs, steroids, non-dihydropyridine CCBs
  • Chest pain, palpitations
  • Known ejection fraction

Examination findings

  • JVP, hepatojugular reflux
  • Crackles, effusions
  • Peripheral edema, ascites
  • Cool peripheries, narrow pulse pressure, confusion (low output)
  • S3, new murmurs

03Investigate

Initial investigations

  • ECG
  • Chest X-ray
  • BNP or NT-proBNP, troponin
  • BMP, magnesium, CBC, LFTs, TSH
  • Point-of-care ultrasound (B-lines, IVC, effusion)

Advanced investigations

  • Echocardiogram if none recent or a change is suspected
  • Iron studies (ferritin, transferrin saturation)
  • Ischemia evaluation for new HFrEF

04Treat

Immediate management

  • Sit upright; oxygen if hypoxic
  • CPAP/BiPAP for pulmonary edema with respiratory distress
  • IV loop diuretic: 1-2.5 times the total daily oral furosemide dose given IV (40 mg IV if diuretic-naive)
  • IV nitroglycerin for hypertensive pulmonary edema

First-line treatment

  • Target net negative 1–2 L/day; check spot urine sodium about 2 hours after the dose and double the loop dose if response is poor
  • Continue GDMT unless hypotensive, in shock or with severe AKI or hyperkalemia
  • Start an SGLT2 inhibitor in hospital once hemodynamically stable (eGFR ≥20–25)
  • Up-titrate GDMT rapidly around discharge (STRONG-HF approach)
  • Treat the precipitant

Second-line treatment

  • Sequential nephron blockade (metolazone or acetazolamide) for diuretic resistance
  • Inotropes for cardiogenic shock with cardiology/ICU
  • IV iron if iron deficient

Specialist referrals

  • Cardiology for new HF, cardiogenic shock or advanced therapies
  • Heart failure nurse or clinic before discharge

05Disposition

Admission criteria

  • Hypoxia or respiratory distress
  • Need for IV diuretics
  • Hypotension, low output, ACS or arrhythmia
  • Worsening renal function or electrolyte disturbance

Safe discharge criteria

  • Euvolemic or near dry weight on oral diuretics for 24 h
  • Stable renal function and electrolytes
  • GDMT started or optimized
  • Follow-up within 7 days

Follow-up timing

  • Clinic visit or call within 7 days of discharge
  • BMP within 1 week

Patient instructions

  • Daily morning weights; call if up 1 kg (2 lb) in a day or 2 kg (5 lb) in a week
  • Sodium under 2 g/day; avoid NSAIDs

Monitoring

  • Daily weight and strict fluid balance
  • Daily BMP and magnesium during IV diuresis

Clinical pearls and pitfalls

  • HFrEF GDMT: ARNI/ACEi/ARB, evidence-based beta-blocker, MRA, SGLT2 inhibitor
  • A small creatinine rise during effective decongestion is acceptable

RefGuidelines and landmark evidence

For education only. Typical adult starting points; confirm doses against renal function, allergies, interactions and your institution's protocols. Not a substitute for clinical judgment or senior review.

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