Q: 62 year old male with history of congestive heart failure (CHF) and previously stable on home medications presented with acute exacerbation of CHF requiring Non Invasive Positive Pressure Ventilation (NIPPV). The recommended required dose of diuretic for this patient?
A) As equal as home dose
B) About 2.5 times of home dose
C) Start with lowest dose
D) furosemide drip with 10 mg/hr
E) Add metolazone to home diuretic dose
Patients with acute exacerbation of CHF who are chronically on diuretics at home usually requires about 2.5 times of their baseline total daily dose. This came from the DOSE trial which showed benefit towards improved clinical symptoms in patients in higher dose arm of the study.
Continuous IV infusion can be initiated but requires IV bolus dose prior to it (choice D).
Metolazone is usually added as a second step when response to diuretic is not desirable (choice E).
Felker GM, Lee KL, Bull DA, et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med 2011; 364:797.