ADHF management & GDMT

Frame the admission

Most ADHF is warm and wet. You still have to say the four words out loud — warm or cold, wet or dry — because the cold patient does not belong on a floor diuretic experiment (). Primary right-sided disease is a different physiology; see Right ventricular failure.

Forrester: warm / cold × wet / dry

Warm · dry
Profile I — compensated
Perfused, euvolemic. Optimize GDMT. This is the discharge target, not the admission.
Warm · wet
Profile II — congested
Most floor / SDU ADHF. Diurese. Add afterload reduction if hypertensive, acute MR, or AR.
Cold · dry
Profile III — low-output
Hypoperfused and empty (or overdiuresed). Cautious fluid if CVP is low; inotrope if still cold. Do not stack loops.
Cold · wet
Profile IV — shock
Classic cardiogenic . CCU, norepinephrine for MAP, inotrope, early -team / MCS conversation.

Cold = AMS, lactate, cool extremities, narrow pulse pressure. Pulmonary edema can be absent on CXR — lymphatics compensate ().

FAILURE — why they decompensated

F
Forgot meds
Non-adherence, cost, “I felt better so I stopped.”
A
Arrhythmia / anemia / afterload
AF with RVR, bleeding, hypertensive emergency.
I
Infection / ischemia
Pneumonia, UTI, ACS. Do not call it “just HF” until you have looked.
L
Lifestyle
Salty diet, missed dry-weight checks.
U
Upregulated output
RVR, thyrotoxicosis, high-output states.
R
Renal failure
Missed dialysis, NSAID, ACE-related AKI.
E
Embolism
PE. Also progression of the CM, inadequate diuretic dose, steroids, alcohol, new valve lesion.

History and admission orders

Prior CM diagnoses and ischemic vs non-ischemic workup, dry weight, NT-proBNP trend, last TTE / EF, NYHA class, habits, meds, risk factors, outpatient cardiologist.
Admission: telemetry, 2 L fluid restriction, 2 g sodium diet, daily standing weights, strict I/Os; SDU electrolyte replacement scales.
Avoid: NSAIDs, non-dihydropyridine CCBs, steroids, flecainide.
Document NT-proBNP and weight on admission and again at discharge. Send the CM / trigger workup; order TTE if none is recent.

Decongestion and the rest of the floor playbook

Treat the trigger (infection, AF with RVR, severe HTN) while you diurese. Offer smoking and alcohol cessation; consult nutrition, OT, and social work when diet or meds clearly drove the admission. Catheter ablation of AF improves mortality in HFrEF (Circ Arrhythm Electrophysiol 2021;14). CRT if EF ≤35% for 3 months on GDMT, LBBB with QRS ≥150 ms, NYHA II–IV.

Diuresis

Drop CVP / PCWP to move back onto a better Starling curve and to make the patient breathe (; ).

Find an effective diuretic dose (EDD): escalate the IV bolus until urine is actually moving (e.g. >150 mL/h).
Re-dose the EDD until the TBB (to-be-given) goal is met — usually net −1 to −2 L.
Refractory: large IV bolus, then a continuous infusion.
Augment: metolazone 2.5–5 mg (or chlorothiazide 500 mg IV) 30 minutes before the loop; acetazolamide 500 mg daily (, ); dapagliflozin 10 mg daily ().

Mild–moderate creatinine rise while still wet is usually not a stop sign (). Cardiorenal type 1 is more under-draining than under-filling.
Endpoints: less congestion on exam, down weight, up Cr / BUN, hemoconcentration, smaller POCUS JVP, fewer B-lines (B-lines track HF admission and death; ).
When the exam is a liar, a PA catheter will tell you whether you actually reached euvolemia.

Afterload, iron, devices, lungs

Vasodilators drop SVR and raise CO — especially in uncontrolled HTN, acute MR, or AR. Floor: isosorbide dinitrate, hydralazine, nitropaste, captopril. SDU / CCU: nitroglycerin infusion, nitroprusside (caution if unrevascularized CAD).
IV iron in HFrEF if ferritin <100, or ferritin ≤300 with TSAT <20%, regardless of hemoglobin (; ; ).
ICD: prior MI with EF ≤30%, or EF ≤35% plus NYHA II–III, after 3 months of GDMT.
Flash pulmonary edema: NIPPV can cut death and intubation ().

GDMT — start it before they leave

If there is no and no AKI, continue home ACE / ARB / ARNi, MRA, and β-blocker (). Fractionate the β-blocker if you plan to titrate. Hold SGLT2i only if a procedure is coming. In HFrEF / HFmrEF / HFimpEF, start low-dose quadruple therapy before discharge (). Keep GDMT after EF recovers (TRED-HF; included recovered EF).

HFrEF vs HFpEF GDMT pillars

ARNi
ARNi / ACE / ARB
HFrEF: sacubitril/valsartan preferred (; ). ACE / ARB if ARNi is unavailable (CONSENSUS; CHARM). 36-hour ACE-inhibitor washout before ARNi. HFpEF: no outcome win (PARAGON-HF; CHARM-Preserved; I-; PEP-CHF).
BB
Evidence-based β-blocker
HFrEF: metoprolol succinate, carvedilol, bisoprolol (; ). Avoid in bradycardia or low-output. Consolidate tartrate to succinate at discharge. HFpEF: no proven benefit ().
MRA
Mineralocorticoid antagonist
HFrEF: spironolactone, eplerenone (; ). HFpEF: signal in the Americas (); finerenone (FINEARTS, ).
SGLT2i
SGLT2 inhibitor
Both phenotypes. HFrEF: dapagliflozin, empagliflozin (; EMPEROR-Reduced). HFpEF: EMPEROR-Preserved, . Hold for procedures, eGFR <20, or recurrent UTIs.

HFpEF: treat DM, HTN, obesity. Semaglutide if obese (). You may continue GDMT when eGFR is <30; start new agents there with caution. AHA/ACC/HFSA 2022 ().

Circ 2022;145:895. Avoid new ACE / ARB / ARNi / MRA in AKI, hypotension, or hyperkalemia. After a new MRA, check K and Cr within 72 hours of discharge — rebound hyperkalemia appears when loops come down.

Drug	Initial	Target
Metoprolol succinate	12.5–25 mg daily	200 mg daily
Carvedilol	3.125 mg BID	25–50 mg BID
Sacubitril/valsartan	49/51 mg BID	97/103 mg BID
Lisinopril	2.5–5 mg daily	20–40 mg daily
Losartan	25–50 mg daily	50–150 mg daily
Spironolactone	12.5–25 mg daily	25–50 mg daily
Eplerenone	25 mg daily	50 mg daily
Dapagliflozin	10 mg daily	10 mg daily
Empagliflozin	10 mg daily	10 mg daily

Predischarge

Write down discharge weight and NT-proBNP, the next cardiology appointment, and a cardiac-rehab referral.
Watch ~24 hours on a maintenance oral diuretic. Decide about potassium replacement. Sliding-scale rescue: extra diuretic if weight is up >3 lb in 24 hours or >5 lb in a week.
Name the outpatient risk-factor moves: GLP-1 RA for weight, CPAP for OSA.