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7.5 Treatment

7.5.1. Oxygen therapy Oxygen therapy is recommended in patients with hypoxaemia [oxygen saturation (SpO2) <90% or partial pressure of oxygen (PaO2) <60 mmHg]. Studies, including RCTs, have demonstrated that indiscriminate oxygen administration in non-hypoxaemic patients may be harmful.499–501

7.5.2 Ventilation support

Non-invasive ventilation is recommended in patients with APO or CS and respiratory failure to improve oxygenation and reduce the need for intubation as shown by multiple trials and meta analyses.502,503 However, the increase in intrathoracic pressure with non-invasive positive pressure ventilation decreases venous return and right and left ventricular preload. It may also decrease cardiac output and blood pressure and should therefore be used with caution in patients with reduced preload reserve and hypotension (i.e. decompensated right-sided HF). Endotracheal intubation is reserved for selected cases (see Recommendation Table 9).477

7.5.3 Diuretics (decongestion management)

Intravenous loop diuretics remain the cornerstone of decongestion in DHF. In the DOSE-AHF trial, no difference in the primary efficacy outcome of patients’ symptom global assessment was shown with a high-dose regimen compared with a low-dose regimen of furosemide. There is no evidence indicating differential outcomes with i.v. bolus administration compared to continuous infusion or that one loop diuretic is superior to another.327,504 Patients naïve to diuretics usually respond well to 40 mg of i.v. furosemide or equivalent, whereas i.v. doses of two times the patient’s usual oral diuretic dose should be considered for patients who have been on loop diuretics as outpatients.505 Possible worsening kidney function should be evaluated in the context of diuretic response, because small and transient rises in serum creatinine during diuretic therapy are not associated with poor outcome if decongestion is achieved.506,507 Subsequent doses of loop diuretics during the initial days of hospitalization may be adjusted based on urinary sodium (uNa+) assessments, diuretic response, and the patient’s clinical status. A satisfactory diuretic response can be defined as a uNa+ content ≥70 mEq/L at 2 h or by a urine output ≥100 mL/h during the first 6 h (Figure 15). The PUSH-AHF trial showed that a strategy based on frequent clinical assessment, and uNa+-guided diuretic therapy led to higher natriuresis at 24 h vs standard of care.508 In the ENACT-HF open-label study, the uNa+-based approach also resulted in higher natriuresis and diuresis, as well as shorter hospital stay.509 No clinical trial has thus far showed benefit of uNa+-guided diuretic therapy on death or recurrent HFH. Intravenous diuretics should be continued until optimal decongestion is achieved; then, a switch to oral diuretics, if needed to maintain the volume status, is recommended. If there is an insufficient diuretic response, the loop diuretic i.v. dose can be doubled and/or a non-loop diuretic added. (Figure 15). Two recent RCTs examined the role of non-loop diuretics for enhanced decongestion in DHF. In the ADVOR trial, patients were randomized to i.v. acetazolamide (500 mg) or placebo added to i.v. loop diuretics. Treatment with acetazolamide resulted in a greater incidence of successful decongestion, defined as the absence of signs of volume overload within 3 days.510 In the CLOROTIC trial, oral hydrochlorothiazide (dose adjusted for eGFR) was compared with placebo in patients receiving i.v. furosemide.511 The treatment with hydrochlorothiazide resulted in more pronounced weight loss at 72 h but did not impact patientreported dyspnoea. Treatment with hydrochlorothiazide was associated with greater 24 h diuresis but also more likely worsened kidney function and hypokalaemia, warranting caution. Importantly, the study was prematurely halted due to slow recruitment. Both ADVOR and CLOROTIC did not show benefit of non-loop diuretics on hard endpoints. The pharmacotherapy of different diuretics and a practical guidance for their use in DHF is reported in Supplementary data online, Table S13. In patients with DHF, fluid intake should be less than urine output and fluid restriction may be appropriate in patients with hyponatraemia, based on individual assessment. Similarly, sodium intake should remain less than natriuresis.

Implementing SGLT2-I and neurohormonal blockade, including MRA, can contribute to more effective and sustainable decongestion.512–514 Thus, it is imperative to consider early implementation and optimization of FMT in parallel to decongestion (Figure 15).

7.5.4 Decongestion management in the ambulatory

setting In ambulatory patients with chronic HF showing signs of worsening, both i.v. diuretic administration and intensification of oral diuretic therapy can be considered. A practical guide for the outpatient management of WHF has been published, covering both ambulatory i.v. diuretics administered in a day-hospital setting and ‘hospital-at-home’ care models, including telehealth-enabled approaches.515–517 Diuretic sessions usually consist of a 3–6 h i.v. diuretic infusion with dosing based on the patient’s existing oral diuretic regimen. Close monitoring of kidney function, electrolyte levels, and treatment response, including measurements of urine output, uNa+, signs of clinical decongestion, biomarkers, and/or ultrasound findings, is essential.444,515,518 The new formulations of diuretics (e.g. subcutaneous) might be particularly useful for home treatment.519–521 Intensification of oral diuretic therapy may include: (i) initiating a loop diuretic in previously untreated individuals; (ii) increasing the total daily dose of a loop diuretic; or (iii) temporarily adding a diuretic with a different mechanism of action. Thiazide-like diuretics—particularly oral metolazone (2.5–5 mg)—can be used in patients with advanced HF who exhibit diuretic resistance, as part of a sequential nephron blockade approach, or in those with an eGFR <30 mL/min/1.73 m2. This strategy requires careful monitoring of eGFR and electrolytes. Patients with WHF that progresses to advanced HF are a key population for either outpatient i.v. diuretic treatment, whether in a day hospital or ‘hospital-at-home’ setting, or oral thiazidelike diuretics. Indeed, these patients often experience frequent hospitalizations and spend a substantial amount of time in hospital (‘frequent flyers’). Such patients require prompt evaluation for advanced HF treatments (see Section 8). Downloaded from academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehag100/8766302 by guest on 31 August 2026