This handout is for acute hf — acute decompensation on chronic hf. Your care team identified this based on: known hfref + new dyspnea/edema/weight gain → acute-on-chronic decompensation.
Other reasons your team may use this plan: known hfpef + new dyspnea/edema → acute-on-chronic hfpef decompensation; hf readmission within 30 days → high-risk acute-on-chronic with precipitant audit mandatory; nt-probnp elevation above patient baseline + symptom progression in known hf.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| furosemide | IV bolus at 2-2.5× home PO dose; if home 80 mg PO daily then 160-200 mg IV q12h or continuous 10-20 mg/h | IV | q6-12h or continuous | DOSE PMID 21366472 — high-dose IV bolus or continuous infusion equivalent; assess UOP at 2h; chronic patients often need higher doses |
| torsemide | 20-40 mg IV (or 100% oral bioavailability if PO) | IV/PO | BID | TRANSFORM-HF (Mentz JAMA 2023) — equivalent outcomes vs furosemide; better PO bioavailability if gut edema |
| acetazolamide | 500 mg IV daily × 3 days | IV | daily × 3 | ADVOR PMID 36027564 — adjunct to IV loop improves decongestion at 3 days |
| sacubitril-valsartan | CONTINUE home dose; if not on ARNI then start 24/26 BID per PIONEER-HF (24h post-AHF, SBP ≥100, K <5.2, eGFR ≥30) | PO | BID | PIONEER-HF PMID 30403955 — in-hospital ARNI initiation/optimization safe + reduces NT-proBNP + 8-week mortality |
| carvedilol | CONTINUE home dose if hemodynamically tolerant (SBP ≥90, HR >60); reduce dose 50% only if hypotensive/bradycardic; do NOT discontinue | PO | BID | B-CONVINCED (Jondeau 2009) + COPERNICUS PMID 11386262 — chronic BB withdrawal during ADHF associated with worse outcomes |
| spironolactone | CONTINUE home dose if K <5 + eGFR ≥30; reduce 50% if K 5.0-5.4 | PO | daily | EMPHASIS-HF PMID 21073363 + RALES PMID 10471456 |
| empagliflozin | CONTINUE 10 mg PO daily if eGFR >20; if not on SGLT2i then START in-hospital per EMPULSE | PO | daily | EMPULSE PMID 35347356 — in-hospital initiation/continuation reduces 90-day mortality + readmit |
| dapagliflozin | 10 mg PO daily | PO | daily | DAPA-HF + DELIVER — alternative SGLT2i |
| nitroglycerin | 5-200 µg/min IV titrate | IV | continuous | Afterload reduction in HTN urgency precipitant; ESC 2021 Class IIa |
Plan: Acute-on-chronic HF — IV diuresis + CONTINUE chronic GDMT + in-hospital ARNI optimization (DOSE; PIONEER-HF; B-CONVINCED; EMPULSE; STRONG-HF)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Discharge with intensified the four foundational heart-failure medications (PIONEER-HF in-hospital ARNI start/up-titration); STRONG-HF cadence (1 wk post-d/c + biweekly × 6 wk); cardiac rehab; precipitant-specific follow-up (e.g., adherence support, AF clinic, dietitian)
Guideline: 2022 ACC/AHA HF + 2023 Focused Update