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Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 May 3, 2022 e963 CLINICAL STATEMENTS AND GUIDELINES

or rehospitalization compared with no carvedilol use.12,13 Discharge use of beta blockers is also associated with lower 30-day all-cause mortality and 4-year all-cause mortality/all-cause readmission.14 Caution should be used when initiating beta blockers in patients who have required inotropes during hospitalization. In GWTG-HF, initiation of ACEi-ARB in patients hospitalized with HFrEF reduced 30-day and 1-year mortality.2 Among patients hospitalized with HFrEF, initiation of ACEi-ARB also is associated with lower risk of 30-day all-cause readmission and allcause mortality.15 In a claims study, initiation of MRA therapy at hospital discharge was associated with improved HF readmission but not mortality or cardiovascular readmission among older adults hospitalized with HFrEF.16 In COACH, initiating spironolactone among patients hospitalized with HFrEF was associated with lower 30-day mortality and HF rehospitalization.3 In the PIONEER-HF trial, ARNi use was associated with reduced NT-proBNP levels in patients hospitalized for acute decompensated HF without increased rates of adverse events (worsening renal function, hyperkalemia, symptomatic hypotension, angioedema) when compared with enalapril.18 In the ARIC study, initiation of any oral GDMT was associated with reduced 1-year mortality among patients hospitalized with HFrEF.5 In SOLOIST-WHF, initiation of sotagliflozin before or shortly after discharge reduced cardiovascular mortality and hospitalization.17 4.	 Nearly half (46%) of patients with HFrEF have no changes made to oral GDMT in the 12 months after hospitalization despite many being discharged on suboptimal doses.21 From claimsbased studies, 42% of patients with HFrEF are not prescribed any GDMT within 30 days post-index hospitalization,20 and 45% are prescribed either no oral GDMT or monotherapy within 1-year post-index hospitalization.21 From CHAMP-HF, initiation or dose increases of beta blockers, ACEi-ARB-ARNi, and MRA occur in ≤10% of patients with HFrEF within 1 year of hospitalization.22 Very few eligible patients with HFrEF receive target doses of beta blockers (18.7%), ACEi-ARB (10.8%), or ARNi (2.0%).6 Less than 1% of patients with HFrEF are on target doses of ACEi-ARB-ARNi, beta blockers, and MRA within 12 months of an index hospitalization.22 For patients with HFrEF, there is a graded improvement in the risk of death or rehospitalization with monotherapy, dual therapy, and triple therapy compared with no GDMT after an index hospitalization in Medicare claims data.21 9.3 Diuretics in Hospitalized Patients: Decongestion Strategy

Recommendations for Diuretics in Hospitalized Patients: Decongestion Strategy Referenced studies that support the recommendations are summarized in the Online Data Supplements.

COR LOE Recommendations

1 B-NR 1.	 Patients with HF admitted with evidence of significant fluid overload should be promptly treated with intravenous loop diuretics to improve symptoms and reduce morbidity.1

1 B-NR 2.	 For patients hospitalized with HF, therapy with diuretics and other guideline-directed medications should be titrated with a goal to resolve clinical evidence of congestion to reduce symptoms and rehospitalizations.1–6

1 B-NR 3.	 For patients requiring diuretic treatment during hospitalization for HF, the discharge regimen should include a plan for adjustment of diuretics to decrease rehospitalizations.7

2a B-NR 4.	 In patients hospitalized with HF when diuresis is inadequate to relieve symptoms and signs of congestion, it is reasonable to intensify the diuretic regimen using either: a. higher doses of intravenous loop diuretics.1,3); or b. addition of a second diuretic.3

Synopsis Intravenous loop diuretic therapy provides the most rapid and effective treatment for signs and symptoms of congestion leading to hospitalization for HF. Titration to achieve effective diuresis may require doubling of initial doses, adding a thiazide diuretic, or adding an MRA that has diuretic effects in addition to its cardiovascular benefits. A major goal of therapy is resolution of the signs and symptoms of congestion before discharge, as persistent congestion scored at discharge has been associated with higher rates of rehospitalizations and mortality. Most patients who have required intravenous diuretic therapy during hospitalization for HF will require prescription of loop diuretics at discharge to decrease recurrence of symptoms and hospitalization.

Recommendation-Specific Supportive Text

1.	 Diuretic therapy with oral furosemide was the cornerstone of HF therapy for >20 years before construction of the modern bases of evidence for HF therapies. The pivotal RCTs showing benefit in ambulatory HFrEF have been conducted on the background of diuretic therapy to treat and prevent recurrence of fluid retention. An RCT compared intravenous diuretic doses and infusion to bolus dosing during hospitalization for HF but without a placebo arm.1 Protocols for recent trials of other medications in patients hospitalized with HF have all included intravenous diuretic therapy

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