What is the management of a new exacerbation of heart failure (HF)?

From the Guidelines

Management of a new heart failure exacerbation requires prompt intervention with a combination of medications and supportive care, focusing on relieving congestion with intravenous loop diuretics and maintaining guideline-directed medical therapy. The initial treatment should focus on relieving congestion with intravenous loop diuretics such as furosemide 40mg IV, which can be increased to 80mg if response is inadequate after 2 hours 1. Oxygen supplementation should be provided to maintain saturation above 92%. For patients with reduced ejection fraction, guideline-directed medical therapy includes ACE inhibitors (e.g., lisinopril 2.5-5mg daily), beta-blockers (e.g., carvedilol 3.125mg twice daily), and mineralocorticoid receptor antagonists (e.g., spironolactone 25mg daily) 1. These medications should be initiated at low doses and gradually uptitrated.

Key Considerations

• Sodium and fluid restriction (2g sodium/day and 1.5-2L fluid/day) is essential 1.
• Daily weight monitoring helps track fluid status.
• Continuous cardiac monitoring is necessary to detect arrhythmias.
• The underlying pathophysiology involves neurohormonal activation and fluid retention, which these interventions target by reducing preload and afterload, inhibiting the renin-angiotensin-aldosterone system, and blocking sympathetic stimulation.
• After stabilization, patients require close follow-up within 7-14 days of discharge to adjust medications and monitor for recurrent symptoms.

Medication Management

• Beta-blocker therapy should be initiated at a low dose and only in stable patients 1.
• ACE inhibitors and beta-blockers should be continued in most patients in the absence of hemodynamic instability or contraindications 1.
• Vasodilators can be used in most patients with AHF, but these drugs should be avoided in those with systolic blood pressure <90 mm Hg and used with caution in patients with severe mitral or aortic stenosis 1.

From the FDA Drug Label

The primary objective of PARADIGM-HF was to determine whether sacubitril and valsartan, a combination of sacubitril and an RAS inhibitor (valsartan), was superior to an RAS inhibitor (enalapril) alone in reducing the risk of the combined endpoint of cardiovascular (CV) death or hospitalization for heart failure (HF)

The management of new heart failure exacerbation is not directly addressed in the provided drug label. The FDA drug label does not answer the question.

From the Research

Management of New Heart Failure Exacerbation

• The management of new heart failure exacerbation involves the use of various medications, including sacubitril-valsartan, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and angiotensin receptor blockers (ARBs) 2, 3, 4, 5, 6.
• Sacubitril-valsartan has been shown to be effective in reducing morbidity and mortality in patients with heart failure and reduced ejection fraction (HFrEF) 2, 3.
• ACE inhibitors and ARBs are also recommended for the management of heart failure, as they have been shown to improve outcomes and reduce hospitalizations 4, 5, 6.
• Beta-blockers are another important class of medications for the management of heart failure, as they have been shown to reduce sudden cardiac death and improve patient outcomes 6.
• The combination of beta-blockers and ACE inhibitors, or the use of newer agents such as angiotensin receptor-neprilysin inhibitors (ARNIs) and mineralocorticoid receptor antagonists (MRAs), may provide additive benefits in the management of heart failure 6.

Treatment Guidelines

• The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure provides recommendations for the management of heart failure, including the use of sacubitril-valsartan, ACE inhibitors, beta-blockers, and ARBs 5.
• The guideline recommends a patient-centric approach to the management of heart failure, with a focus on preventing, diagnosing, and managing the condition 5.
• The guideline also emphasizes the importance of evidence-based medicine in the management of heart failure, and provides recommendations based on contemporary evidence 5.

Medication Selection

• The selection of medications for the management of heart failure should be based on the individual patient's needs and characteristics, including their ejection fraction, symptoms, and comorbidities 2, 3, 4, 5, 6.
• Sacubitril-valsartan may be a good option for patients with HFrEF, as it has been shown to reduce morbidity and mortality in this population 2, 3.
• ACE inhibitors and ARBs may be a good option for patients with heart failure and preserved ejection fraction (HFpEF), as they have been shown to improve outcomes and reduce hospitalizations in this population 4, 5, 6.
• Beta-blockers may be a good option for patients with heart failure and reduced ejection fraction, as they have been shown to reduce sudden cardiac death and improve patient outcomes 6.