No No Warm and Dry Cold and Dry Yes Yes Warm and Wet Cold and Wet Congestion at rest? (e.g. orthopnea, elevated jugular venous pressure, pulmonary rales, S3 gallop, edema) (e.g. narrow pulse pressure, cool extremities, hypotension) Low perfusion at rest? Figure 4. Classi cation of patients presenting with acutely decompensated heart failure. Adapted with permission from Nohria et al. (306). JACC Vol. 62, No. 16, 2013 Yancy et al. October 15, 2013:1495 539 2013 ACCF/AHA Heart Failure Guidelines: Executive Summary 3. The effect of HF treatment should be monitored with careful measurement of uid intake and output, vital signs, body weight that is determined at the same time each day, and clinical signs and symptoms of systemic perfusion and congestion. Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of intravenous diuretics or active titration of HF medi- cations. (Level of Evidence: C) CLASS IIa 1. When diuresis is inadequate to relieve symptoms, it is reasonable to intensify the diuretic regimen using either: a. higher doses of intravenous loop diuretics (37,312) (Level of Evidence: B); b. addition of a second (e.g., thiazide) diuretic (313 316). (Level of Evidence: B) CLASS IIb 1. Low-dose dopamine infusion may be considered in addition to loop diuretic therapy to improve diuresis and better preserve renal function and renal blood ow (317,318). (Level of Evidence: B) 7.4. Renal Replacement Therapyd Ultra ltration CLASS IIb 1. Ultra ltration may be considered for patients with obvious volume overload to alleviate congestive symptoms and uid weight (319). (Level of Evidence: B) 2. Ultra ltration may be considered for patients with refractory congestion not responding to medical therapy. (Level of Evidence: C) 7.5. Parenteral Therapy in Hospitalized HF CLASS IIb 1. 