Forrester Classifications and Treatments

Warm and dry

Optimize chronic oral medications (GDMT)

Warm and wet

IV loop diuretic

• If patient not achieving adequate urine output, need to either:

  • Increase loop dose

  • Change to continuous IV administration

  • Add-on thiazide-like diuretic (metolazone, chlorothiazide, hydrochlorothiazide)

±

IV vasodilator

• ONLY if patient has adequate urine output on loop diuretic but still has s/s of volume overload

• Choose nitroprusside if patient needs significant BP reduction (e.g. BP 180/100 mmHg)

Cold and dry, PCWP <15

IV fluids

Cold and dry, PCWP 15-18

If SBP <90mmHg

• IV inotrope

  • May add vasopressor if inotrope alone not enough cardiac output increase to help blood pressure

If SBP ≥90mmHg

• IV vasodilator — nitroglycerin if SBP is only a little over 90, nitroprusside if it’s considerably over 90

Cold and wet

If SBP <90mmHg

• IV loop diuretic

• +

• IV inotrope

  • May add vasopressor if inotrope enough not enough cardiac output increase to help blood pressure

If SBP ≥90mmHg

• IV diuretic

• ±

• IV vasodilator

  • Only if patient is still hypoperfused and needs more cardiac output than the IV diuretic alone can give

    • If patient needs more cardiac output + SBP is close to being 90mmHg or less, wait to see if loop diuretic will give them enough cardiac output before starting IV vasodilator

    • If patient needs more cardiac output + SBP is well above 90mmHg, start vasodilator too immediately

  • Choosing nitroglycerin vs nitroprusside

    • Nitroglycerin if SBP is close to being 90mmHg or less

    • Nitroprusside if SBP is well above 90mmHg (bc has more hypotensive effects)