Recommendation 132: We recommend supplemental oxygen be considered for patients who are hypoxemic; titrated to an oxygen saturation > 90% (Strong Recommendation, Moderate Quality Evidence).

Values and preferences: This recommendation places higher value on the physiologic studies demonstrating potential harm with the use of excess oxygen in normoxic patients and less value on long-term clinical usage of supplemental oxygen without supportive data.

Recommendation 133: We recommend that morphine not be used routinely in patients with AHF (Strong Recommendation, Moderate Quality Evidence).

Values and preferences: This recommendation places higher value on large epidemiological studies with appropriate methods demonstrating harm with the use of morphine in patients with AHF.

Recommendation 134: We recommend that CPAP or BIPAP not be used routinely in/for patients with AHF (Strong Recommendation, Moderate Quality Evidence).

Values and preferences: This recommendation places high weight on RCT data with a demonstrated lack of efficacy and with safety concerns in routine use. Treatment with BIPAP/CPAP might be appropriate for patients with persistent hypoxia (SpO2 < 90%), high respiratory rate (> 25 breaths per minute) and pulmonary edema despite other appropriate therapies.

Recommendation 135: We recommend that intravenous diuretics be given as first line therapy for patients with pulmonary or peripheral congestion (Strong Recommendation, Low Quality Evidence).

Recommendation 136: We recommend that for patients requiring intravenous diuretic therapy, furosemide may be dosed intermittently (e.g., twice daily) or as a continuous infusion (Strong Recommendation, Moderate Quality Evidence).

• When acute congestion is cleared, the lowest dose that is compatible with stable signs and symptoms should be used.
• Target 0.5 – 1.0 kg of weight loss per 24 hour period while a patient with volume overload is actively diuresing. Patients who are losing < 0.5 kg per day despite at least 40 mg of IV furosemide will need a reassessment of fluid status and may be diuretic resistant.
• Once transitioned from IV to oral diuretic therapy, the stability of symptoms, weight and hemodynamics should be observed for ~24 hours prior to hospital discharge.
• To transition a patient to oral diuretics, be aware that the oral version of furosemide has ~50% bioavailability compared to IV furosemide.

Recommendation 137: We recommend the following intravenous vasodilators for relief of dyspnea in hemodynamically stable patients (SBP > 100 mm Hg):

1. Nitroglycerin (Weak Recommendation, Moderate Quality Evidence);
2. Nesiritide (Weak Recommendation, High Quality Evidence);
3. Nitroprusside (Weak Recommendation, Very Low Quality Evidence).

Values and preferences: This recommendation places a high value on the relief of the symptom of dyspnea and less value on the lack of efficacy of vasodilators or diuretics to reduce hospitalization or mortality.

Practical tip:
In situations in which intravenous nitroglycerin is not appropriate or available, repeated sublingual nitroglycerin, a nitroglycerin patch, or oral isosorbide dinitrate might be useful for dyspnea relief in patients with a SBP > 100 mm Hg.

Recommendation 138: We recommend that hemodynamically stable patients not routinely receive inotropes like dobutamine, dopamine, levosimendan or milrinone (Strong Recommendation, High Quality Evidence).

Values and preferences: This recommendation for inotropes place high value on the potential harm demonstrated when systematically studied in clinical trials and less value on potential short-term hemodynamic effects of inotropes.

• Intravenous vasoconstrictor agents (e.g., phenylephrine, norepinephrine) should generally be avoided for AHF management except for patients with hypotensive with SBP < 90 mmHg, associated signs or symptoms, end-organ damage and a significant change from baseline.
• In patients with low SBP (< 90 mmHg), low cardiac output and either euvolemia or hypervolemia, inotropes may be used for stabilization.

Recommendation 139: We recommend continuation of chronic beta-blocker therapy in a patient with AHF, unless the patient is symptomatic from hypotension or bradycardia (Strong Recommendation, Moderate Quality Evidence).

Practical tip:
A major reduction in dose or abrupt beta-blocker withdrawal should be avoided in the case of worsening HF. If the patient is hypotensive, consider reducing the dose of other medications before reducing the beta-blocker dosage. Temporary discontinuation might occasionally be necessary in patients with shock. Whenever possible, reinstitution of treatment should be attempted before hospital discharge.

Recommendation 140: We suggest that tolvaptan be considered for patients with volume overload, hyponatremia (< 130 mmol/L) and symptoms of hyponatremia for the short-term correction of hyponatremia and associated symptoms (Weak Recommendation, Moderate Quality Evidence).

Values and preferences: This recommendation places higher value on the correction of symptoms and complications related to hyponatremia and less value on the efficacy of vasopressin antagonists to reduce HF related hospitalizations or mortality.