2024 ACC Hospitalized Heart Failure Guidelines — Quick Reference

Overview & Key Metrics

Hospitalization for heart failure remains a major healthcare burden, with 1-year mortality of 20–35% post-discharge and up to 50% at 2 years. This guideline emphasizes systematic approach to decongestion, neurohormonal modulation during acute decompensation, and discharge planning to reduce rehospitalization.

Key Principle: The clinical trajectory during hospitalization—defined by pace and extent of decongestion and hemodynamic response—guides intensity of therapy and determines candidacy for continued optimization vs. escalation to invasive monitoring or advanced therapies.

Major Changes from 2019 ECDP

Update	Evidence	Clinical Impact
SGLT2i in Hospital	SOLOIST-WHF, EMPACT-AHF showing improved diuresis	Now initiated on day 1 in most HFrEF patients
ARNI Early Initiation	PIONEER-HF, TRANSITION trials with sacubitril/valsartan	Consider after stabilization even with SBP 100–110 mmHg
In-Hospital GDMT Completion	Get With the Guidelines-HF registry outcomes	Target all 4 pillars at discharge when feasible
Diuretic Escalation	ADVOR (acetazolamide), CLOROTIC (dual blockade)	Acetazolamide × 3 days or thiazide addition reduces LOS

Admission Assessment & Risk Stratification

Initial triage determines acuity level and appropriate care setting (hospitalization vs. ED observation vs. hospital-at-home for selected patients).

Risk Stratification for Admission

Admission Decision Algorithm

Assess Presentation: Dyspnea, orthopnea, peripheral edema, elevated JVP, rales, BNP/NT-proBNP elevation. 1

Evaluate Hemodynamics: SBP, HR, perfusion, hypotension (<90), cardiogenic shock. 1

Assess Organ Dysfunction: Creatinine, BUN, potassium, troponin, liver function. 2a

Evaluate Social Factors: Ability to take oral meds, follow-up access, caregiver support. 2a

Admission Labs & Metrics

Test	Actionable Findings	Next Step
BNP/NT-proBNP	Elevated confirms volume overload	Guides diuresis intensity; serial measurement not for day-to-day
Creatinine & eGFR	Baseline for drug dosing; GFR <30 limits ARNI/MRA	Use CKD-EPI eGFR
Potassium	High K+ (>5.5) or low K+ (<3.5) affects drug selection	Correct hypokalemia before MRA; hold MRA if K+ >5.5
Albumin	Low albumin (<3.0) reduces oncotic pressure	Use caution with aggressive diuresis; may deplete intravascular volume
Echocardiogram	LVEF, diastolic function, RV function, TR jet, RA pressure	Determines HFrEF/HFmrEF/HFpEF; guides GDMT choice

Evaluation of Congestion & Volume Status

Accurate assessment of intravascular and extravascular fluid compartments guides diuretic intensity and prevents "overshooting".

Clinical Assessment of Congestion

Finding	Interpretation	Action
Elevated JVP ≥8 cm H₂O	Elevated right atrial pressure; volume overload sign	Increase IV diuretic dosing
Orthopnea / PND	Pulmonary congestion with elevated LA pressure	Escalate IV diuretic dosing
Rales on exam	Pulmonary edema; hospitalization risk	Target for early diuresis
Peripheral edema	Extravascular accumulation; unreliable if hypoalbuminemia	Caution: if albumin <3.0, avoid overshooting diuresis
Weight loss ≥2–3 lbs/day	Adequate diuretic response	Track daily; target euvolemia
Worsening renal function	Cardiorenal syndrome or overshooting	Assess JVP to determine under- or over-diuresed

Pearl — Hypoalbuminemia & Decongestion: Patients with albumin <3.0 g/dL have reduced plasma oncotic pressure. Peripheral edema may persist despite intravascular depletion. These patients have 6-fold higher in-hospital mortality and require cautious diuresis without aggressive IV loop diuretics without careful monitoring.

Diuretic Therapy & Dosing

Establishing an effective diuretic regimen is crucial for achieving decongestion. Initial dosing is based on prior home diuretic use or estimated fluid overload.

Initial IV Diuretic Dosing

Drug Class	Agent	Initial Inpatient Dosing	Maximum Daily	Notes
Loop	Furosemide IV	40–80 mg IV q12h; or 1–2.5× home dose	200–400 mg/dose	DOSE trial: 2.5× dose strategy led to 43% more weight loss
Loop	Bumetanide IV	0.5–2 mg IV q12h	12 mg/day	More predictable bioavailability
Thiazide	Metolazone PO	2.5–5 mg once or twice daily (for dual blockade)	20 mg/day	Add if inadequate loop response; peak effect 1 hour
CAI	Acetazolamide	500 mg PO/IV daily (use × 3 days)	N/A	ADVOR: acetazolamide × 3 days increased decongestion rate, shorter LOS

Diuretic Response & Escalation

Diuretic Titration Algorithm

Step 1 — Initial IV Bolus: Start with calculated IV furosemide dose. Monitor weight loss, urine output, Cr, K+. 1

Step 2 — Assess Response at 2 Hours: Check spot urine sodium (if available). Urine Na <50 mEq/L → poor response. 2a

Step 3 — Escalate if Inadequate: Double IV furosemide or increase frequency to q8–12h. Evaluate for cardiorenal syndrome or alternative diagnosis. 2a

Step 4 — Continuous Infusion vs. Boluses: Cochrane review suggests infusion may yield greater net diuresis. Use 5–20 mg/h furosemide infusion if frequent dosing needed. 2b

Step 5 — Dual Nephron Blockade for Refractory Congestion: If furosemide ≥400–500 mg/day inadequate, add metolazone 2.5–5 mg PO once or twice daily OR acetazolamide 500 mg daily × 3 days. 2a

DO: Diuretic Best Practices

Assess clinical congestion at baseline and daily (JVP, orthopnea, edema, weight)
Start with bold doses for symptom relief; 2.5× dose strategy improves dyspnea by 72h
Monitor spot urine sodium when diuretic response uncertain
Use continuous infusion if patient requires frequent dosing (q8h)
Add thiazide or acetazolamide early if on >240 mg/day furosemide equivalent
Check electrolytes & Cr every 24–48h during active diuresis

DON'T: Common Diuretic Errors

Don't use doses that are too low; undershooting prolongs hospitalization
Don't ignore the "stalled" trajectory; escalate to invasive monitoring by day 2–3
Don't discontinue then restart IV diuretics mid-hospitalization (associated with higher mortality)
Don't use aggressive diuresis in hypoalbuminemia <3.0 without careful hemodynamic assessment

Clinical Trajectories During Hospitalization

Three main in-hospital trajectories, each with distinct management implications.

Three In-Hospital Trajectories

Improving Toward Target

Decongestion progresses, dyspnea improves, JVP normalizes, weight loss steady, labs stable. Up-titrate GDMT. Accelerate discharge planning.

Initial Response, Then Stalled

Improves first 24–48h, then plateaus. Weight loss slows, labs worsen. Re-evaluate for alternative diagnosis. Escalate diuretics. Consider invasive monitoring.

Not Improved or Worsening

No diuretic response, hemodynamic deterioration, cardiogenic shock. Initiate IV inotropic/vasopressor support. Discuss goals of care.

Trajectory Management Algorithm

Assess Daily Trajectory

Improving Trajectory: Up-titrate all 4 GDMT pillars. Continue IV diuretics until euvolemia, then transition to oral. Plan discharge within 4–5 days. 1

Stalled Trajectory: Re-evaluate diagnosis. Reassess volume compartments. Escalate diuretics (dual blockade). Consider invasive monitoring if diagnosis uncertain. 2a

Worsening Trajectory: Discontinue vasodilators/ARNI/ACE-I temporarily. Initiate IV inotropic support. Obtain invasive monitoring. Discuss goals of care. 1

Key Insight: Patients who had IV diuretics stopped and restarted during hospitalization had higher early mortality and readmission rates. Avoid stopping diuretics mid-hospitalization without strong clinical reason.

SGLT2 Inhibitors During Hospitalization

SGLT2 inhibitors (dapagliflozin, empagliflozin) are now recommended for all HFrEF patients and should be initiated during hospitalization, typically on admission day 1–2 after stabilization.

Initiation Criteria & Dosing

Agent	HF Indication	Dosing	Baseline Labs	COR
Dapagliflozin	HFrEF or HFmrEF (EF ≤40%)	10 mg PO daily (5 mg if eGFR <30)	Glucose, eGFR, UA	1
Empagliflozin	HFrEF (≤40%); HFpEF (>40%)	10 mg PO daily (5 mg if <60 kg or eGFR <30)	Glucose, eGFR, UA	1

Benefits During Hospitalization

Enhanced diuresis: Increases osmotic diuresis via glycosuria
Improved decongestion: Faster weight loss in SOLOIST-WHF, EMPACT-AHF trials
Renal protection: May preserve renal function during aggressive diuresis
Long-term outcomes: In-hospital initiation linked to higher continued use at 12 months

Safety Monitoring

SGLT2i Safety Checklist

Baseline Assessment: Confirm eGFR >20 (dapagliflozin) or >15 (empagliflozin). Hold if acute kidney injury or active UTI. 1

Monitoring During Use: Check glucose, electrolytes, Cr daily × 3–5 days. Screen for genital infection signs. 2a

Discontinuation Triggers: Hold if acute kidney injury (Cr rise >0.5), DKA, or acute abdomen. 2a

Pearl — Financial Feasibility: Before discharge, assess whether patient can access SGLT2i outpatient. If cost prohibitive, prioritize other GDMT pillars at discharge; restart SGLT2i once financial access arranged.

GDMT Optimization: Neurohormonal Modulators

After stabilization, initiate or up-titrate all 4 pillars of GDMT: SGLT2i, beta-blocker, ARNI/ACE-I/ARB, and MRA. Order and pace depend on HF presentation and baseline therapy.

Stability Criteria for Neurohormonal Modulation

SBP ≥100 mmHg without IV inotropes in past 24 hours
No increase in IV diuretic dosing or vasodilator requirement in past 6 hours
Improving or stable renal function
Potassium <5.5
No acute coronary syndrome

New-Onset HFrEF Strategy

Initiation for De Novo HFrEF

Day 1–2: SGLT2 Inhibitor + Diuretics 1

After Stabilization: Add Beta-Blocker

Metoprolol succinate: Start 6.25–12.5 mg daily; target 190 mg daily
Carvedilol: Start 3.125 mg BID; target 25 mg BID

1

Add RAS Inhibitor (ARNI Preferred):

Sacubitril/Valsartan: Start 24/26 mg BID; titrate to 97/103 mg BID
PIONEER-HF: 34% new HF, showed benefit for sacubitril/valsartan

1

Add MRA (if eGFR >30, K <5.5): Spironolactone 25 mg daily; monitor K+ & Cr at 1, 3, 7 days. 2a

Sacubitril/Valsartan (ARNI) Dosing by Profile

Presentation	Starting Dose	Target Dose	Key Considerations
New HFrEF, SBP 118	24/26 mg BID	97/103 mg BID	PIONEER-HF: safe & effective; reduces rehospitalizations
Chronic HFrEF, SBP <100	24/26 mg BID or low ARB dose first	49/51 mg BID if SBP borderline	TRANSITION: dosing achievable even with lower SBP
Prior ACE-I	Hold ACE-I ≥36h before ARNI; start 24/26 mg BID	Standard titration	Washout avoids angioedema risk
Prior ARB	Switch directly; no washout needed	Standard titration	Direct switch reduces treatment gap

Pearl — ARNI Timing: Optimal initiation occurs when patients are at mid-to-upper range of normal filling pressures (post-diuresis but before overshooting). This minimizes vasodilation risk while ensuring ARNI benefit.

DO: GDMT Best Practices

Prescribe all 4 pillars at discharge unless contraindicated
In-hospital initiation linked to higher medication adherence at 12 months
Use GDMT Optimizer for target-dose selection
Schedule early follow-up (within 7 days) to monitor tolerability & adjust

IV Vasodilators and Inotropic Agents

Reserved for stalled or worsening trajectory: refractory to IV diuretics, hypotensive, or in cardiogenic shock. Require hemodynamic monitoring and ICU care.

IV Vasodilator Indications & Dosing

Agent	Mechanism	Dosing	Indication
Nitroglycerin IV	Venous + arterial vasodilation	5–200 mcg/min; titrate to SBP goal	Pulmonary HTN, elevated filling pressures, hypertensive HF
Nitroprusside IV	Balanced vasodilation (arterial > venous)	0.3–5 mcg/kg/min	Hypertensive HF with pulmonary edema requiring rapid afterload reduction

IV Inotropic Agents

Agent	Dosing	Use Case	Mortality Risk
Dobutamine	2.5–10 mcg/kg/min IV	Low-output shock (SBP <90, elevated lactate)	Associated with increased mortality; reserve for acute stabilization <24–48h
Milrinone	0.25–0.75 mcg/kg/min IV	Cardiogenic shock with elevated SVR; pulmonary HTN	Systemic hypotension common; often requires concurrent pressor support

Pitfall — Inotrope Dependency: Prolonged inotropic support worsens long-term outcomes. Use as bridge to mechanical support or definitive care planning (palliative/hospice if not VAD candidate).

Hemodynamic Monitoring

For stalled or worsening trajectories, invasive monitoring (Swan-Ganz catheter) clarifies hemodynamic profile and guides therapy escalation.

Hemodynamic Profiles & Management

Profile	Characteristics	Management	Goal
Warm/Dry	CI ≥2.5, PCWP <18	Continue current regimen; taper IV diuretics	Target discharge
Warm/Wet	CI ≥2.5, PCWP ≥18	Escalate IV diuretics ± vasodilators	Reduce PCWP to <18; achieve euvolemia
Cold/Wet	CI <2.5, PCWP ≥18	Inotrope ± vasodilator. Judicious diuresis.	Improve CI; reduce PCWP. Consider mechanical support if refractory.

Pearl — SCAI Shock Classification: Use the SCAI Shock Classification calculator to stage shock severity (A–D) and guide escalation decisions (IABP, ECMO, VAD).

Transition from IV to Oral Diuretics

Timing is critical. Premature discontinuation causes early readmission; delayed transition prolongs hospital stay unnecessarily.

Readiness Criteria for Transition

IV-to-Oral Transition Checklist

Clinical Decongestion Achieved: No orthopnea, dyspnea improved, JVP ≤8 cm H₂O, minimal edema, lung exam clear. 1

Hemodynamically Stable: SBP ≥100 mmHg without IV inotropes, HR appropriate. 1

Renal Function Stable: Creatinine plateau or improving (not rising >0.2 in 48h). 1

Tolerating Oral Intake: No nausea/vomiting, can take PO safely. 2a

Daily Weights Stable: <2 lbs fluctuation day-to-day indicates equilibrium.

Oral Diuretic Dosing Strategy

Transition Approach	When to Use	Dosing Logic
Direct switch at equivalent dose	Patient was on stable home oral diuretic	Resume home diuretic dose (e.g., furosemide 80 mg daily → resume 80 mg daily PO)
Estimate maintenance from IV requirement	Diuretic-naive or on low home dose	Oral bioavailability 10–30% lower than IV. If required 320 mg IV daily, estimate 80–120 mg furosemide PO daily.
Empiric for new-onset HF	De novo HF, unknown baseline	Start 40 mg furosemide daily or 12.5 mg chlorthalidone daily; double if inadequate response

DO: Transition Best Practices

Document clear oral diuretic regimen at discharge (name, dose, frequency)
Educate patient on daily weight monitoring and symptom recognition
Provide written instructions on when to increase/decrease diuretics
Schedule early follow-up within 3–7 days
Ensure Labs (BMP, Cr, K) ordered for within 7 days if on MRA

Discharge Readiness & Planning

Comprehensive discharge planning reduces 30-day readmission risk. Timing typically 4–7 days for uncomplicated HF.

Discharge Safety Criteria Checklist

Before Discharge

Hemodynamic Stability: SBP ≥100 mmHg without IV support, HR 60–100, no dyspnea at rest. 1

Adequate Decongestion: JVP normal, no orthopnea, minimal edema, clear lung exam. (Discharge with congestion → 28% 1-year mortality vs. 18.5% without.) 1

Renal Function & Electrolytes Acceptable: Cr stable, K+ 3.5–5.5. 1

GDMT Prescribed: All 4 pillars (SGLT2i, BB, ARNI/ACE-I/ARB, MRA) with doses & frequency. 1

Patient/Caregiver Education Completed: HF pathophysiology, medication adherence, daily weight monitoring, fluid/sodium restriction. 2a

Follow-Up Care Arranged: First visit within 7 days; phone contact 48h post-discharge. 2a

Labs Ordered: BMP (Cr, K) within 3–7 days if on MRA or new diuretic. 2a

Activity & Lifestyle Recommendations

Activity: Resume ADLs; gradual increase in exertion. No strenuous exercise until cleared by cardiologist.
Sodium: ≤2–3 g/day (reduces HF symptom burden)
Fluid: 1.5–2 L/day if hyponatremia (Na <130); otherwise 2 L/day typical
Alcohol: Avoid excess; abstinence if alcohol-induced cardiomyopathy
Weight goal: Maintain within 2–3 lbs of discharge; call if gain >3 lbs in 3 days

Pearl — Early Post-Discharge Follow-Up: Clinic visit within 7 days (vs. >30 days) is associated with lower 30-day readmission risk. Schedule before discharge and confirm appointment.

Post-Discharge Management & Follow-Up

Continued GDMT optimization, monitoring for fluid recurrence, and readmission prevention are the goals in weeks and months after discharge.

First Follow-Up Visit (Within 7 Days)

Assessment	Action	Intervention Threshold
Symptom Review	Dyspnea, orthopnea, PND, leg swelling, chest pain	New/worsening dyspnea → reassess; may need IV diuretics if severe
Weight & Vital Signs	Confirm weight stable (<2–3 lbs from discharge)	Weight gain >3 lbs + symptoms → diuretic escalation or IV diuresis
GDMT Tolerability	Review adherence; ask about side effects (dizziness, cough, GI upset)	Intolerable side effects → discuss management strategies or agent switch
BMP: Cr, K+, Na+	Check within 3–7 days if on MRA or new diuretic	K+ >5.5 or Cr rise >0.3 → hold MRA; recheck in 1 week
Physical Exam	JVP, lung exam, peripheral edema, orthostatic vitals	Congestion signs → increase diuretic or IV diuresis

GDMT Uptitration Post-Discharge

Goal: Reach Target Doses by 4–8 Weeks Post-Discharge

Week 1–2: Verify Tolerance & increase GDMT if SBP >110 mmHg

Week 2–4: Target Dose Achievement for beta-blocker, ARNI, MRA

Week 4–8: Consolidation & Monitoring Verify target doses tolerated; repeat BMP

Ongoing Monitoring

Interval	Assessment	Action
Monthly (first 3 months)	Phone call or clinic visit; symptoms, adherence, weight trends, BP	Adjust GDMT doses; reinforce weight monitoring
Every 3 months (thereafter)	Clinic visit; BMP if on MRA; QOL, exercise tolerance	Continue GDMT at target if stable; consider advanced HF therapies if EF remains low
Echocardiogram	Baseline (if not done); repeat at 3–6 months	If EF improves >40%, may de-escalate GDMT; if ≤35%, optimize for ICD/CRT candidacy

DO: Post-Discharge Best Practices

Schedule first follow-up before discharge and confirm appointment
Call patient within 48–72 hours to confirm medication receipt & assess symptoms
Provide written diuretic adjustment plan (e.g., "increase furosemide to 80 mg BID if weight gain >3 lbs in 3 days")
Enroll high-risk patients in remote monitoring programs (daily weight, pulse oximetry)
Refer to cardiac rehabilitation

Clinical Pearls & Pitfalls

Pearl 1 — The "Stalled" Trajectory: Patients who improve then plateau by day 2–3 are at highest risk. Early escalation (diuretic intensification, invasive monitoring) is critical. Escalate within 48h of stalling.

Pearl 2 — Discharge with Residual Congestion: ESC-EORP registry: 1-year mortality 28% with discharge congestion vs. 18.5% without. Push hard for complete decongestion before discharge.

Pearl 3 — Hypoalbuminemia Changes Diuretics: In patients with albumin <3.0 g/dL, peripheral edema may persist despite intravascular depletion. Aggressive diuresis risks cardiorenal syndrome. Use cautious, slower diuresis.

Pearl 4 — SGLT2i + Loop Diuretics Synergize: SGLT2 inhibitors add osmotic diuresis via glycosuria, enhancing fluid loss. Reassess and often reduce diuretic regimen after SGLT2i initiation to avoid overshooting.

Pearl 5 — In-Hospital GDMT Completion Predicts Adherence: Prescription of all 4 pillars at discharge predicts sustained use at 12 months. Even if doses not at target, discharge prescription matters greatly.

Pearl 6 — IV Diuretic "Stop-Restart" is a Red Flag: Stopping then restarting IV diuretics mid-hospitalization is associated with higher mortality & readmission. Plan with clear exit strategy: euvolemia + oral transition, or ongoing IV until discharge.

Pearl 7 — Acetazolamide × 3 Days Works: ADVOR trial: acetazolamide 500 mg daily for 3 days increased successful decongestion (42% vs. 31%) and shortened LOS by 1 day. Discontinue after 3 days to avoid chronic acid-base issues.

Pitfall 1 — Undershooting Diuretics: Fear of worsening renal function sometimes leads to under-diuresis, prolonging hospitalization. DOSE trial showed higher-dose strategy improved symptom relief by 72h without increased mortality.

Pitfall 2 — Forgetting MRA: Spironolactone reduces hospitalization & mortality yet is underutilized. Initiate in hospital if eGFR >30 & K <5.5; monitoring is feasible (recheck at 1 week, then monthly × 3). Don't let barriers prevent initiation.

Pitfall 3 — Discharge Without Clear Follow-Up: Lack of scheduled follow-up or vague instructions increases 30-day readmission 2–3 fold. Always schedule appointment before discharge and confirm with patient/family.

Related Calculators & Tools

Use these integrated SattiMD calculators at key decision points during hospitalization and follow-up.

2024 ACC Expert Consensus Decision Pathway on Hospitalized Heart Failure