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May 3, 2022 Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 e964

CLINICAL STATEMENTS AND GUIDELINES as background therapy.1–6,8,9 There are no RCTs for hospitalized patients comparing intravenous loop diuretics to placebo, for which equipoise is considered unlikely.10

2.	 Monitoring HF treatment includes careful measurement of fluid intake and output, vital signs, standing body weight at the same time each day, and clinical signs and symptoms of congestion and hypoperfusion. Daily laboratory tests during active medication adjustment include serum electrolytes, urea nitrogen, and creatinine concentrations. Signs and symptoms of congestion have been specified as inclusion criteria in recent trials of patients hospitalized for HF, in which resolution of these signs and symptoms has been defined as a goal to be achieved by hospital discharge,1–6,8,9 as it has in the recent HF hospitalization pathway consensus document.11 Evidence of persistent congestion at discharge has been reported in 25% to 50% of patients,4,5,12 who have higher rates of mortality and readmission and are more likely to have elevated right atrial pressures, TR, and renal dysfunction. Diuresis should not be discontinued prematurely because of small changes in serum creatinine,13,14 because elevations in the range of 0.3 mg/dL do not predict worse outcomes except when patients are discharged with persistent congestion. Decongestion often requires not only diuresis but also adjustment of other guideline-directed therapies, because elevated volume status and vasoconstriction can contribute to elevated filling pressures. 3.	 After discharge, ACEi-ARB, MRAs, and beta blockers all may decrease recurrent congestion leading to hospitalization in HFrEF. Despite these therapies, most patients with recent HF hospitalization require continued use of diuretics after discharge to prevent recurrent fluid retention and hospitalization, as shown in a recent large observational analysis.7 Increases in diuretic doses are frequently required early after discharge even in patients on all other currently recommended therapies for HFrEF.8 It is unknown how increased penetration of therapy with ARNi and SGLT2i will, in the future, affect the dosing of diuretics after discharge with HFrEF. 4.	 Titration of diuretics has been described in multiple recent trials of patients hospitalized with HF, often initiated with at least 2 times the daily home diuretic dose (mg to mg) administered intravenously.1 Escalating attempts to achieve net diuresis include serial doubling of intravenous loop diuretic doses, which can be done by bolus or infusion, and sequential nephron blockade with addition of a thiazide diuretic, as detailed specifically in the protocol for the diuretic arms of the CARRESS and ROSE trials.3,9 In the DOSE (Diuretic Optimization Strategies Evaluation) trial, there were no significant differences in patients’ global assessment of symptoms or in the change in renal function when diuretic therapy was administered by bolus, compared with continuous infusion or at a high dose compared with a low dose. Patients in the low-dose group were more likely to require a 50% increase in the dose at 48 hours than were those in the highdose group, and all treatment groups had higher doses of diuretics compared with baseline preadmission doses, underlining the necessity to intensify and individualize diuretic regimen.1 MRAs have mild diuretics properties and addition of MRAs can help with diuresis in addition to significant cardiovascular benefits in patients with HF. Addition of low-dose dopamine to diuretic therapy in the setting of reduced eGFR did not improve outcomes in a study that included patients with all EFs, but a subset analysis showed increased urine output and weight loss in patients with LVEF <0.40,9 with significant interaction of effect with LVEF. Bedside ultrafiltration initiated early after admission increased fluid loss, with decreased rehospitalizations in some studies when compared with use of diuretics without systematic escalation.15,16and was also associated with adverse events related to the intravenous catheters required.3 Many aspects of ultrafiltration including patient selection, fluid removal rates, venous access, prevention of therapy-related complications, and cost require further investigation.

9.4a. Parenteral Vasodilation Therapy in Patients Hospitalized With HF Recommendation for Parenteral Vasodilation Therapy in Patients Hospitalized With HF Referenced studies that support the recommendation are summarized in the Online Data Supplements.

COR LOE Recommendation

2b B-NR 1.	 In patients who are admitted with decompensated HF, in the absence of systemic hypotension, intravenous nitroglycerin or nitroprusside may be considered as an adjuvant to diuretic therapy for relief of dyspnea.1,2

Synopsis Vasodilators can be used in acute HF to acutely relieve symptoms of pulmonary congestion in selected patients. Although they may mitigate dyspnea and relieve pulmonary congestion, their benefits have not been shown to have durable effects for either rehospitalization or mortality benefit. In select patients who present with signs of hypoperfusion such as worsening renal function, even in the absence of hypotension, other escalation of care may need to be considered (see Section 8.3, “Inotropic Support,” and Section 9.5, “Evaluation and Management of Cardiogenic Shock”).

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