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• In advanced heart failure (HF), each hospitalization for decompensation requires optimizing pharmacological treatment. • Changes made in the treatment of patients admitted for decompensated advanced HF depend on their hemodynamic clinical profile. • In daily clinical practice, HF drugs are increased an optimized occurs in advanced decompensated HF with a pulmonary or systemic congestion profile. • When the profile is low cardiac output, there is a tendency to reduce or suspend drugs, especially beta blockers and diuretics. In advanced heart failure (HF), each hospitalization for decompensation is a vulnerable moment, and it requires optimizing pharmacologic treatment. This study aimed to analyze changes in the pharmacologic treatment of HF before admission (P), during hospitalization (H), and at discharge (D) of patients with decompensated advanced HF. We performed an ambispective, cross-sectional, noninterventional study conducted from January 2020 to June 2020. There were 252 consecutive patients admitted for decompensated advanced HF. The following were excluded: de novo HF cases, deceased patients, and scheduled admissions. Finally, 134 patients were analyzed, compared in 3 subgroups: pulmonary congestion (n = 90), systemic congestion (n = 31), and low output (n = 13). In the global analysis, an increase was detected in angiotensin receptor and neprilysin inhibitors (P: 9.7%, H: 16.4, D: 22.4%; P <.02), beta blockers (P: 67.2%, H: 77.6%, D: 84.3%; P <.004), mineralocorticoid receptor antagonists (P: 29.9%, H: 44.4%, D: 46.3%; P <.01), loop diuretics (P: 70.1%, H: 99.3%, D: 95.5%; P <.001), and nitrates (P: 6.0%, H: 22.4%, D: 9.7%; P <.001). Pulmonary congestion was predominant with a significant increase in beta blockers (P: 61.1%, H: 77.8%, D: 88.9%; P <.001) and loop diuretics (P: 64.4%, H: 100%, D: 100%; P <.001); diuretics were increased in the systemic congestion group (P: 80.6%, H: 100%, D: 100%; P <.002), and 22.6% required 3% hypertonic saline solution. In patients with low output, beta blockers and diuretics were withdrawn (P: 84.6%, H: 76.9%, D: 46.1%; P <.08 and P: 84.6%, H: 92.3%, D: 61.5%; P <.1 respectively), without variation in the other pharmacologic groups. In daily clinical practice, HF drugs are increased and optimized in decompensated HF with a pulmonary or systemic congestion profile. When the profile is low output, beta blockers and diuretics are reduced. [ABSTRACT FROM AUTHOR]