Initiation of Congestive Heart Failure Action Plan in the Emergency Department

In Medical Concepts by Anthony LauLeave a Comment

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. 


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.

Drawing Parallels With Asthma Action Plans

A widely-used, pre-existing concept that is similar to a sliding scale furosemide protocol is an
asthma action plan. An asthma action plan is a written template that is produced for the purpose of
patient self-management of asthma exacerbations. It provides instructions on how and when a
patient needs to self-adjust medications in response to worsening asthma, and how to seek medical
assistance in such situations.​5​ A Cochrane review conducted by Gibson et al. analyzed 36
randomized controlled trials that compared self-management to usual care in patients with asthma.
The review found that self-management education, which involved a written action plan, self-
monitoring and regular medical review, reduced ED and unscheduled primary care visits, asthma-
related hospitalizations, and improved patient health outcomes.​5​

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
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.)

When is a CHF Action Plan Appropriate?

A patient self-directed CHF action plan may be appropriate for a specific subgroup of
patients who have adequate health literacy, motivation in their self-care, absence of cognitive
impairment issues, and close monitoring with longitudinal follow-up for their CHF management.
Given that the ED is a common point of contact for many patients with CHF exacerbations,
widespread implementation of a patient-directed furosemide protocol upon discharge from the ED
may significantly improve patient outcomes and reduce overall burden on the healthcare system.
The implications and benefits of implementing this action plan may also be translated to CHF
patients discharged from the medical wards. Furthermore, the utility of this approach may be
translated to the EDs in the USA and UK, where similarly, ED crowding is a prevalent issue as demand
for ED services commonly exceeds available resources.

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

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.


In summary, we propose the concept of implementing a simplified, weight-based, patient-
directed CHF action plan in the ED. This underutilized tool may be a useful method for clinicians to
help CHF patients maintain euvolemia in the community, and subsequently reduce ED visits and
CHF-related rehospitalizations. Further well-designed clinical trials comparing different diuretic
dosing strategies are suggested to evaluate the optimal CHF outpatient management approach.


The patient provided written informed consent for the inclusion of their case in this article and its
subsequent publication for medical education.

The article was edited by Brent Thoma and copy-edited by George V. Kachkovski.


  1. 1.
    2016 Report on the Health of Canadians: The Burden of Heart Failure. Heart and Stroke Foundation of Canada. Accessed July 16, 2022. files/canada/2017-heart-month/heartandstroke-reportonhealth-2016.ashx?la=en.
  2. 2.
    Kuipers SJ, Cramm JM, Nieboer AP. The importance of patient-centered care and co-creation of care for satisfaction with care and physical and social well-being of patients with multi-morbidity in the primary care setting. BMC Health Serv Res. Published online January 8, 2019. doi:10.1186/s12913-018-3818-y
  3. 3.
    Chaudhry SI, Wang Y, Concato J, Gill TM, Krumholz HM. Patterns of Weight Change Preceding Hospitalization for Heart Failure. Circulation. Published online October 2, 2007:1549-1554. doi:10.1161/circulationaha.107.690768
  4. 4.
    Khan YH, Sarriff A, Adnan AS, Khan AH, Mallhi TH. Chronic Kidney Disease, Fluid Overload and Diuretics: A Complicated Triangle. Joles JA, ed. PLoS ONE. Published online July 21, 2016:e0159335. doi:10.1371/journal.pone.0159335
  5. 5.
    Gibson PG, Powell H, Wilson A, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database of Systematic Reviews. Published online July 22, 2002. doi:10.1002/14651858.cd001117
  6. 6.
    Zhao Q, Chen C, Zhang J, Ye Y, Fan X. Effects of self-management interventions on heart failure: Systematic review and meta-analysis of randomized controlled trials – Reprint. International Journal of Nursing Studies. Published online April 2021:103909. doi:10.1016/j.ijnurstu.2021.103909
  7. 7.
    DeWalt DA, Malone RM, Bryant ME, et al. A heart failure self-management program for patients of all literacy levels: A randomized, controlled trial [ISRCTN11535170]. BMC Health Serv Res. Published online December 2006. doi:10.1186/1472-6963-6-30
  8. 8.
    Prasun MA, Kocheril AG, Klass PH, Dunlap SH, Piano MR. The Effects of a Sliding Scale Diuretic Titration Protocol in Patients With Heart Failure. The Journal of Cardiovascular Nursing. Published online January 2005:62-70. doi:10.1097/00005082-200501000-00012
  9. 9.
    Niznick J. How to adjust your diuretic dose [PDF file]. Continuing Medical Implementation Inc. Published 2020. Accessed June 25, 2022.
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Anthony Lau

Anthony Lau is a Clinical Pharmacy Specialist in Emergency Medicine at Vancouver General Hospital. He is currently a Clinical Instructor with the Faculty of Pharmaceutical Sciences at the University of British Columbia and a Board Certified Pharmacotherapy Specialist through the Board of Pharmacy Specialties. His clinical interests are in pharmacokinetics and pharmacology. No conflicts of interest.

Dillon Lee

Dillon Lee: Dillon Lee is a Clinical Pharmacist at Vancouver General Hospital, providing patient care in Internal Medicine, Emergency Medicine, and Orthopedic Surgery. She also serves as a preceptor for pharmacy students at UBC, guiding them in direct patient care and directed studies projects. Dillon is passionate about advocating for the advancement of pharmacy practice and scope. No conflicts of interest.

Lilian Shi

Lilian Shi is a Clinical Pharmacist at Rockyview General Hospital. Her clinical interests are in Cardiology. No conflicts of interest.

Grace Wang

Grace Wang is a Pharmacist at Vancouver General Hospital. Her clinical interests and passions are in the areas of emergency medicine and antimicrobial and opioid stewardship. No conflicts of interest.

Annie Song

Annie Song is an EDiCare physician at Vancouver General Hospital. She is also a long term care physician with the HomeVIVE program, focusing on geriatric medicine and care. Her interest is in helping support patients at home and strategies for improving quality of life in the elderly. No conflicts of interest.

Christopher Lee

Christopher Lee is an Emergency Physician at Vancouver General Hospital. He is also an associate medical director for BC Health Emergency Management, a lead physician for VGH Disaster Management, and a clinical assistant professor for UBC Faculty and Department of Emergency Medicine. No conflicts of interest.