Practical outpatient management of worsening chronic heart failure

Abstract

Management of worsening heart failure (WHF) has traditionally been hospital-based, but with the rising burden of heart failure (HF), the pressure on healthcare systems exerted by this disease necessitates a different strategy than long (and costly) hospital stays. A strategy for outpatient intravenous (IV) diuretic treatment of WHF has been developed in certain American centres in the past 10 years, whereas European centres have been mostly favouring 'classic' in-hospital management of WHF. Embracing novel, outpatient approaches for treating WHF could substantially reduce the burden on healthcare systems while improving patient's satisfaction and quality of life. The present article is intended to provide essential knowledge and practical guidelines aimed at helping clinicians implement these new ambulatory approaches using day hospital and/or at-home hospitalization. The topics addressed by our group of HF experts include the pathophysiological background of diuretic therapy, the most suitable profile of WHF that may be managed in an ambulatory setting, the pharmacological protocols that can be used, as well as a detailed description of healthcare structures that can be proposed to deliver these ambulatory care interventions. The practical aspects of day hospital and hospital-at-home IV diuretic administration are specifically emphasized. The algorithm provided along with the practical IV diuretic protocols should assist HF clinicians in implementing this new approach in their local clinical setting.

Keywords: Ambulatory management; Cardiac congestion; Cardiovascular diseases; Diuretics; Heart failure.

Figure 1

Nephron sites and target ion channels with approximate natriuresis/diuresis effect of the various diuretic classes. Cl, chloride; ENaC, epithelial sodium channel; GFR, glomerular filtration rate; K, potassium; IV, intravenous; Na, sodium; RAAS, renin–angiotensin–aldosterone system; SE, side effect; SGLT2, sodium–glucose cotransporter 2.

Figure 2

Shift in dose–response relation to furosemide in patients with chronic heart failure (CHF). Renal function (as measured by estimated glomerular filtration rate) has an important impact on the dose–response curve to furosemide: Higher dosing is needed for lower estimated glomerular filtration rate. This is the underlying reason of the right shift observed for patients with CHF and cardiorenal syndrome and/or chronic kidney disease (CKD) (orange curve). IV, intravenous. Adapted from Brater

Figure 3

Framework for ambulatory intravenous (IV) diuretics use. AF, atrial fibrillation; ER, emergency room; GP, general practitioner; HF, heart failure; NYHA, New York Heart Association; PE, pulmonary embolism; WHF, worsening heart failure.

Figure 4

Ambulatory intravenous (IV) diuretics protocol according to maintenance loop diuretic dose. These doses are general guidelines that need to be adapted to renal function. Patients with estimated glomerular filtration rate <30 ml/min/1.73 m² usually need higher (usually doubled) diuretic dose. ARNi, angiotensin receptor–neprilysin inhibitor; BP, blood pressure; HR, heart rate; MRA, mineralocorticoid receptor antagonist; RAASi, renin–angiotensin–aldosterone inhibitor; SGLT2i, sodium–glucose cotransporter 2 inhibitor.