Table 28

Recommendations for Therapies in the Hospitalized HF Patient

RecommendationsCORLOEReferences
HF patients hospitalized with fluid overload should be treated with intravenous diureticsIB737,738
HF patients receiving loop diuretic therapy should receive an initial parenteral dose greater than or equal to their chronic oral daily dose; then dose should be serially adjustedIB739
HFrEF patients requiring HF hospitalization on GDMT should continue GDMT except in cases of hemodynamic instability or where contraindicatedIB195,735,736
Initiation of beta-blocker therapy at a low dose is recommended after optimization of volume status and discontinuation of intravenous agentsIB195,735,736
Thrombosis/thromboembolism prophylaxis is recommended for patients hospitalized with HFIB21,770–774
Serum electrolytes, urea nitrogen, and creatinine should be measured during titration of HF medications, including diureticsICN/A
When diuresis is inadequate, it is reasonable to a. give higher doses of intravenous loop diuretics; or b. add a second diuretic (e.g., thiazide)IIaB38,739
B740–743
Low-dose dopamine infusion may be considered with loop diuretics to improve diuresisIIbB744,745
Ultrafiltration may be considered for patients with obvious volume overloadIIbB752
Ultrafiltration may be considered for patients with refractory congestionIIbCN/A
Intravenous nitroglycerin, nitroprusside, or nesiritide may be considered an adjuvant to diuretic therapy for stable patients with HFIIbA760–763
In patients hospitalized with volume overload and severe hyponatremia, vasopressin antagonists may be considered IIbB787,788

COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; LOE, Level of Evidence; and N/A, not available.