Decongest, then build
A sequence for the patient admitted with decompensated heart failure: profile, dose, escalate, build foundational therapy, and discharge — updated for the 2026 ESC guideline.
Reviewed October 2026 · verify against current guidelines
Decongest, then build.
A sequence for the patient admitted with decompensated heart failure: the first hour, the first six hours, the first three days, and the handoff home.
Profile · Dose · Escalate · Build · Discharge
Two questions at the bedside.
Is the patient congested? Is the patient perfused? The answers set the first move.
Congested? Perfused?
| Warm and wet | The usual admission. IV loop diuretic without delay. Then measure the response. |
|---|---|
| Cold and wet | Congested and hypoperfused. Shock pathway. Stage it, call the shock team, plan inotrope or mechanical support. |
| Warm and dry | Compensated. Symptoms need another explanation. Look before you diurese. |
| Cold and dry | Low output, low filling. Uncommon. Assess filling before giving or removing volume. |
Wet = orthopnea, raised JVP, edema, rales. Cold = cool limbs, confusion, oliguria, rising lactate.
Precipitants to name in the first hour
- Acute coronary syndrome
- Arrhythmia, often AF with rapid rate
- Infection
- Missed doses, salt or fluid load
- Hypertensive emergency
- Pulmonary embolism
- Acute valve lesion or tamponade
- NSAIDs, steroids, negative inotropes
What the workup is for.
Each test should confirm the diagnosis, find the precipitant, or set a baseline for what comes next.
| BNP or NT-proBNP Supports the diagnosis | Lower in obesity. Higher with AF, kidney disease and age. A normal value makes DHF unlikely. |
|---|---|
| ECG Rhythm, ischemia | AF with a rapid rate or new ischemic change redirects the first hour. |
| Troponin Myocardial injury | Often modestly raised in DHF. A rise and fall with symptoms points to ACS. |
| Echocardiogram LVEF, valves, RV, pericardium | Urgent when unstable or a mechanical cause is possible. LVEF below 50% is now HFrEF. |
| Lung ultrasound B-lines, effusions | Shows pulmonary congestion where trained staff are available. Repeatable, so it can track decongestion. |
| Chemistry Creatinine, K, Na | Baseline before diuresis and RAS blockade. Repeat at least daily during treatment. |
Also order
Lactate if perfusion is in doubt · liver tests for congestive hepatopathy · TSH · ferritin and TSAT before discharge, since iron deficiency is treatable.
The first six hours.
Give enough loop diuretic, then check the response within hours instead of waiting for the next morning.
| 0 h | IV loop diuretic. Loop-naive: furosemide 40 mg IV. Already on a loop: twice the usual oral dose, given IV. |
|---|---|
| 2 h | Spot urine sodium. Adequate at 70 mmol/L or more. Below that, double the IV dose. |
| 6 h | Hourly urine output. Adequate at 100 mL/h or more. Below that, double again. Ceiling: furosemide 600 mg/day, up to 1,000 mg in severe kidney impairment. |
What the trials found
| DOSE, 2011 · n = 308 | 2.5 times the home dose vs 1 times: no significant difference in global symptoms. More fluid and weight loss, more dyspnea relief, more transient creatinine rise. Bolus every 12 h matched continuous infusion. |
|---|---|
| PUSH-AHF, 2023 · n = 310 | Sodium-guided escalation raised 24-hour natriuresis, 409 vs 345 mmol. No difference in death or HF readmission at 180 days. |
When the loop isn't enough.
Block sodium at a second site. 2026 ESC: short-term IV acetazolamide or oral hydrochlorothiazide should be considered in patients already on a loop diuretic (class IIa).
Acetazolamide · proximal tubule
Dose in ADVOR: 500 mg IV once daily for 3 days, on top of IV loop at twice the oral dose.
ADVOR results · acetazolamide vs placebo
| Decongested, day 3 | 42.2% vs 30.5% |
|---|---|
| Hospital stay, days | 8.8 vs 9.9 |
| Death or HF readmission, 3 months | 29.7% vs 27.8% |
Faster decongestion, no outcome difference.
Thiazide · distal tubule
- Oral hydrochlorothiazide carries the same class IIa as acetazolamide.
- Potent with a loop. Expect hypokalemia and a creatinine rise; check electrolytes and creatinine at least daily.
- Kidney function guides the choice. Acetazolamide may be preferable in more advanced CKD.
Build the foundation in hospital.
The admission is the best chance to start foundational medical therapy (FMT), the 2026 ESC name for the core drug classes.
When to start each class
| SGLT2 inhibitor | After initial stabilization, at any LVEF. Recommended, class I. |
|---|---|
| MRA | As potassium and kidney function allow. Class I at any LVEF. |
| Beta-blocker | Continue unless there are clear signs of hypoperfusion. Start or uptitrate as hemodynamics allow. |
| ARNI, ACEi or ARB | As blood pressure and kidney function allow. |
Beta-blocker and RAS inhibitor are FMT for HFrEF only; SGLT2 inhibitor and MRA apply at any LVEF.
STRONG-HF, 2022 · n = 1,078
Half of target doses by discharge, full doses within 2 weeks of discharge, with frequent early visits. Death or HF readmission at 180 days: 15.2% vs 23.3%, driven by fewer readmissions. More adverse events by day 90 (41% vs 29%), the excess mainly hypotension, hyperkalemia and kidney impairment; serious events similar. Few patients took an SGLT2 inhibitor or ARNI.
Where decongestion goes wrong.
Most failures come from stopping too early, overshooting, or missing the patient who is cold.
| Do | Don't |
|---|---|
| Accept a creatinine rise while the patient is decongesting. In ADVOR it was not linked to worse outcomes. | Stop the diuretic for creatinine alone while the patient is still congested. |
| Review the trajectory every day. If response stalls, revisit the cause. | Stop FMT over a creatinine change. Misreading kidney function is a leading cause of undertreatment. |
| Confirm decongestion before discharge. In ADVOR it predicted fewer events, with or without a creatinine rise. | Stop FMT on admission without clear signs of hypoperfusion. |
| Bring in the shock team when temporary MCS is on the table (class I). | Place an IABP in unselected cardiogenic shock. 2026 ESC: not recommended. |
Before they go home.
Discharge is a step in the titration, not the end of it.
Discharge checklist
- Decongested on exam and imaging, not only lighter
- Precipitant named and treated
- Oral diuretic dose chosen, with a plan to adjust it
- SGLT2 inhibitor started; other FMT started or scheduled
- Early visit and labs booked for the next uptitration step
- Cardiac rehabilitation referral (2026 ESC, class IIa)
Educational reference only — not medical advice. Verify against local protocol.
Sources
Verify against current guidelines and local protocol before acting.
- Køber L, Adamo M, et al. 2026 ESC Guidelines for the management of heart failure. Eur Heart J 2026;47:5346–5457.
- Hollenberg SM, et al. 2024 ACC Expert Consensus Decision Pathway on clinical assessment, management, and trajectory of patients hospitalized with heart failure, focused update. J Am Coll Cardiol 2024;84:1241–67.
- Felker GM, et al. DOSE — diuretic strategies in patients with acute decompensated heart failure. N Engl J Med 2011;364:797–805.
- Mullens W, et al. ADVOR — acetazolamide in acute decompensated heart failure with volume overload. N Engl J Med 2022;387:1185–95.
- ter Maaten JM, et al. PUSH-AHF — natriuresis-guided diuretic therapy in acute heart failure. Nat Med 2023;29:2625–32.
- Mebazaa A, et al. STRONG-HF — safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure. Lancet 2022;400:1938–52.
- Meekers E, et al. Renal function and decongestion with acetazolamide in acute decompensated heart failure: the ADVOR trial. Eur Heart J 2023;44:3672–82.
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