Initiation of Congestive Heart Failure Action Plan in the Emergency Department

A 72-year-old English-speaking male with a history of congestive heart failure (CHF) with
reduced ejection fraction (EF) presented to the emergency department (ED) with acute
decompensated CHF. He had a two-year history of progressive dyspnea and exercise intolerance.
Other comorbidities included coronary artery disease, hypertension, dyslipidemia, cardioembolic
stroke, and gastroesophageal reflux disease. His medications included furosemide, apixaban,
atorvastatin, carvedilol, and fosinopril. His furosemide was reduced from 40 mg to 20 mg daily by his
family physician five months prior to presentation.

The patient presented with a two-day history of progressive dyspnea and orthopnea. ED
assessment revealed an elevated jugular venous pressure, decreased air entry bilaterally, and lung
base crackles. On admission, his heart rate was 92 beats/minute, blood pressure 137/91 mmHg, and
respiratory rate of 34 breaths/minute, requiring 15L of supplemental oxygen. Initial laboratory tests
were sodium 142 mmol/L, potassium 3.6 mmol/L, serum creatinine 111 μmol/L, estimated
glomerular filtration rate 57 mL/min/1.73m 2 , and NT-proBNP 2083 ng/L. A chest x-ray showed frank
pulmonary edema and transthoracic echocardiogram which estimated a reduced EF of 29%.
Following admission, the patient required BiPAP for respiratory support due to severe pulmonary
congestion, which was managed by IV nitroglycerin infusion and IV furosemide 40 mg. Furosemide
continued until the patient was weaned off oxygen. Once euvolemic without signs of congestion, he
was transitioned to furosemide 40 mg orally daily. He continued to receive LV-enhancing therapy,
which included ramipril, carvedilol, and the initiation of spironolactone. Euvolemia was achieved
when his weight decreased from 90.2 kg to 84.9 kg. 

Background

CHF is a chronic cardiac condition that affects over 750,000 Canadian individuals and carries
notable mortality and morbidity risks, which imposes substantial financial burden on the healthcare
system through frequent hospitalizations and ED visits.^​1​ According to national estimates from the
Canadian Institute of Health Information for 2013-2014, there were 60,000 recorded ED visits for
decompensated CHF, resulting in a direct cost of $2.8 billion to the overburdened healthcare system
annually. (1) One major area of CHF quality improvement has focused on early optimization of
medical treatment to prevent CHF progression and exacerbations, while simultaneously reducing the
number of related ED visits and hospitalizations.

Loop diuretics, especially furosemide, are the mainstay therapy for preventing volume
overload caused by sodium and fluid retention in CHF. Fluid status can be highly dynamic,
necessitating careful and timely adjustments to their diuretic therapy. A delay in diuretic dose
adjustment can result in rapid fluid accumulation and subsequent decompensation, or conversely,
significant dehydration resulting in pre-renal acute kidney injury.

The Case for Patient-Directed Dosing of Furosemide

Incorporating a patient-directed sliding scale furosemide protocol into the broader CHF
action plan may reduce the risk of adverse events while promoting patient-centered care and co-
creation of care and encouraging proactive engagement in patients’ own CHF management.^​2​ CHF
symptoms and body weight can be used as an approximate marker of volume overload. An average
increase in body weight of more than 0.9 kg is associated with increased risk of CHF-related
hospitalizations, which commonly occurs at least one week prior to admission.^​3​ By encouraging
patients to track their daily weight and recognize signs of worsening CHF, they can adjust their
diuretic dose, preventing volume overload and heart failure decompensation.^​3​ Conversely,
furosemide is also associated with adverse renal outcomes from over-diuresis if fixed doses are not
reduced in a timely manner.^​4​

The adoption of a CHF action plan involves patients documenting their daily weight and adjusting
their furosemide dose according to a sliding scale diuretic model. This approach empowers patients
to be proactive in managing their own health to prevent CHF exacerbations, which has the potential
to offer comparable advantages to an asthma action plan.

Summarizing the Evidence

Asthma action plans and patient-directed sliding scale furosemide regimens have much in
common, as multiple studies have also previously demonstrated that a self-management
intervention in CHF patients leads to decreased hospital readmissions and improved quality of life.^​6​

• DeWalt et al. conducted a randomised controlled trial (RCT) in which patients were enrolled
  in a heart failure self-management program.^​7​ The program involved a 1-hour educational
  session with either a clinical pharmacist or health educator, and joint decision-making
  among the patient, educator, and physician facilitated the development of a personalised
  diuretic dosing plan. Over the course of 12 months, patients participating in the self-
  management program experienced a trend of reduced hospitalizations and deaths
  compared to standard care.
• Another RCT, conducted by Prasun et al., compared patients following a flexible diuretic
  titration (DT) to patients receiving standard care.^​8​ In the DT group, patients were required
  to complete a daily 6-item diuretic titration protocol to determine their daily diuretic dose.
  At the 3-month follow-up, the DT group experienced a significant reduction in ED visits
  compared to the standard care group (3% vs. 28%; p=0.015).

However, the sliding scales used in these studies were either individually tailored or based
on inefficient daily self-questionnaires, which may lead to limitations in a real world setting where
there is often a lack of resources to facilitate and support patient compliance. In practice, simplified
weight-based furosemide dosing tools have been proposed for furosemide outpatient titration,^{​9​ ​10​} but to our knowledge, there have been no studies investigating the efficacy, safety, and
feasibility of these protocols in a real-life practice setting.

While they have not been studied as extensively, we recommend using the sliding scale
protocols developed by Niznick or Kosar, over the sliding scale regimens from the studies, as it
provides an easy-to-follow, resource-sparing, yet comprehensive management approach, which
supports its feasibility of implementing these protocols in a fast-paced, front-line setting such as the
ED. (Figure 1)

Dry weight: 80 kg
Usual home furosemide regimen: 40 mg orally once daily
Weigh at the same time every day, using same scale. Record weight on a daily record.
If weight increases to 82 kg, take an extra furosemide 20 mg for 2 days.
If weight decreases to 78 kg, reduce furosemide dose by 20 mg for 2 days.
Change back to usual furosemide dose as weight returns to 80 kg and swelling/symptoms are
resolved.
If weight continues to increase or decrease, see doctor immediately.

Figure 1. Example of CHF Action Plan Furosemide Dosing (Adapted from Niznick et al.; Kosar et al.)

Back to the Case

The patient was discharged on oral furosemide 40 mg daily and other LV-enhancing
medications. We implemented a CHF action plan for ongoing volume management. The healthcare team instructed him to adjust the furosemide based on weight and symptoms, adhering to the
sliding-scale protocol by Kosar et al. This protocol consisted of increasing oral furosemide by 20 mg
daily as needed for weight gain of more than 1 kg in 1 day or 2.5 kg in 1 week, and reducing oral
furosemide by 20 mg daily as needed for a weight loss of more than 1 kg in 1 day or 2.5 kg over a
week. 

At five-month follow-up, the patient denied dyspnea, orthopnea, or pitting edema. He self-
adjusted his furosemide on four occasions over five months. His weight remained between 78.4 kg
and 83.8 kg, without further hospitalizations for CHF exacerbation since implementing the regimen.
His EF improved to 38%. He shared that he felt extremely motivated and engaged in self-managing
and monitoring his heart failure using the CHF action plan.