This SHM Converge 2025 session focused on the adult inpatient management of heart failure (HF), with an emphasis on diuretic strategies and guideline-directed medical therapy (GDMT) for both HF with reduced ejection fraction (HFrEF), meaning a left ventricular ejection fraction no higher than 40%, and heart failure with preserved ejection fraction (HFpEF), a left ventricular ejection fraction of at least 50%. The presentation was primarily based on guidelines from the American College of Cardiology and the American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC).
The presenters (Salman Rahman, MD, medical director of advanced heart failure hospitalist service and assistant professor at the University of California in San Francisco and Laura Derry, MD, MBA, clinical assistant professor of medicine and hospitalist at Stanford School of Medicine in Stanford, Calif.) began by emphasizing the urgency of improving outcomes, referencing 2017 data showing a five-year mortality rate of approximately 75% in hospitalized patients with HF regardless of ejection fraction.1 This was contrasted with recent studies demonstrating the mortality and hospitalization benefits of current GDMT, as outlined in the ACC/AHA and ESC guidelines.
In HFpEF, the ESC now gives the initiation of sodium-glucose transport protein 2 inhibitors (SGLT2i) a class I recommendation. Recent studies show a relative risk reduction of 58% for death and further HF hospitalizations. The SUMMIT and STEP-HFpEF studies demonstrated that glucagon-like peptide one agonists (GLP-1) will likely be a key component of upcoming guidelines for patients with obesity and HFpEF, given that this led to a 38% reduction in cardiovascular death or worsening HF events.2
ACC/AHA guidelines reflect a class I recommendation for HFrEF patients starting “quadruple therapy,” which comprises beta-blockers (BB), mineralocorticoid receptor antagonists (MRA), SGLT2i, and lastly, renin-angiotensin-aldosterone system inhibitors (RAASi).
One of the most impactful slides of the session shared that, by initiating GDMT for HFrEF, an overall relative risk reduction of 72.9% and an absolute risk reduction of 25.5% in this patient population was seen, leading to a number needed to treat of only 3.9 over 24 months.3,4 The improved mortality discussion was further augmented by a recent study showing that comprehensive GDMT leads to an additional 6.3 years of life for a 55-year-old.5
Having firmly established the benefits of GDMT, our presenters focused on two key goals of hospitalization: improving symptoms through aggressive diuresis within the first 24 hours and improving mortality with rapid initiation of GDMT.
A common starting point for diuresis is either twice the patient’s home dose or at least 40 mg IV furosemide. Within two to three hours of administration, patients should produce approximately 200 to 300 mL of urine. If this target is not met, the diuretic dose should be doubled until maximum dosing is reached. Additional agents such as thiazides or acetazolamide can be used if needed. Urine sodium levels may also be a useful metric during early optimization.
Most patients require two to three diuretic doses daily, with a goal of 3 to 5 liters of diuresis per day. In cases of severe volume overload, higher diuresis goals may be necessary, potentially requiring twice-daily electrolyte monitoring. For HFrEF patients who fail to achieve diuresis goals within the first 24 hours, consultation with a specialist should be considered to evaluate the need for inotropes, dialysis, or right heart catheterization.
Prior to discharge, patients should be euvolemic on an appropriate oral diuretic regimen. Discharge education should include monitoring for signs of decompensation (e.g., weight gain, edema, orthopnea) and have a clear plan to address these issues to prevent rehospitalization.
Ensuring patients are discharged on GDMT can be challenging. A recent study found that only 15.3% of eligible patients left the hospital on full GDMT. 6 Early involvement of case management is essential to assess financial barriers to medications like angiotensin receptor-neprilysin inhibitors (ARNIs) and SGLT2i. GDMT should be initiated throughout the hospital stay and not delayed until the day of discharge, barring any strong contraindications.
Initiation of renin-angiotensin-aldosterone system inhibitors (RAASi) therapy is preferred early in admission. ARNI should be started at least 36 hours after the last angiotensin-converting enzyme inhibitor dose, if systolic blood pressure is at least 100 mmHg, estimated glomerular filtration rate is over 30 mL/min/1.73m², and Child-Pugh score is B or better. Dose titration may occur every 48 hours, with adjustments to the diuretic regimen based on creatinine levels and clinical response.
MRA offers a mortality benefit with minimal impact on blood pressure and should start following RAASi therapy if not already on board. If MRA-naïve, spironolactone should be initiated at 12.5 mg, with a target dose of 25 mg, provided the patient’s estimated glomerular filtration rate is over 30 mL/min/1.73m² and serum potassium is under 5 mEq/L. Ideal creatinine thresholds are below 2.5 mg/dL for men and 2.0 mg/dL for women. If gynecomastia is a concern, eplerenone is an alternative.
SGLT2i are contraindicated for patients with type 1 diabetes. The most common side effect is urogenital infection, and caution is advised in patients at high risk for diabetic ketoacidosis. Notably, empagliflozin does not have a specific renal function cutoff.
Beta-blockers (carvedilol, metoprolol succinate, and bisoprolol) should generally be continued unless the patient is in cardiogenic shock or has significant hypotension or persistent bradycardia. Discontinuation of home beta-blockers is associated with increased mortality. However, these agents are best tolerated near euvolemia, so dose reductions may be appropriate during hospitalization.
All patients with HF—especially those starting new medications—require timely follow-up and ongoing laboratory monitoring.
Key Takeaways
- GDMT, consisting of “quadruple” therapy (ARNI, MRA, BB, and SGLT2 inhibitor), is considered a standard of care and carries a Class I recommendation per ACC/AHA guidelines for HFrEF patients.
- For HFrEF patients, reevaluate your diuresis strategy with urine output two to three hours post initiation of diuresis to see if you need to increase dosing or add in secondary agents.
- SGLT2i has a role in all classes of heart failure. The ESC has moved them to a Class I recommendation for HFpEF.
Dr. Singh is an associate professor at the University of New Mexico-Sandoval Regional Medical Center in Rio Rancho, N.M., and currently serves as the past president for SHM’s New Mexico chapter.
References
- Shah KS, et al. Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes. J Am Coll Cardiol. 2017;70(20):2476-2486. doi:10.1016/j.jacc.2017.08.074.
- Packer M, et al. Tirzepatide for heart failure with preserved ejection fraction and obesity. N Engl J Med. 2025;392(5):427-437. doi:10.1056/NEJMoa2410027.
- Fonarow GC, et al. Potential impact of optimal implementation of evidence-based heart failure therapies on mortality. Am Heart J. 2011;161(6):1024-30.e3. doi:10.1016/j.ahj.2011.01.027.
- Bassi NS, et al. Association of optimal implementation of sodium-glucose cotransporter 2 inhibitor therapy with outcome for patients with heart failure. JAMA Cardiol. 2020;5(8):948-951. doi:10.1001/jamacardio.. 2020.0898.
- Vaduganathan M, et al. Estimating lifetime benefits of comprehensive disease-modifying pharmacological therapies in patients with heart failure with reduced ejection fraction: a comparative analysis of three randomised controlled trials. Lancet. 2020;396(10244):121-128. doi:10.1016/S0140-6736(20)30748-0.6.
- Swat SA, et al. Opportunities and achievement of medication initiation among inpatients with heart failure with reduced ejection fraction. JACC Heart Fail. 2023;11(8 Pt 1):918-929. doi:10.1016/j.jchf.2023.04.015.