From the Guidelines
Heart failure treatment should prioritize a combination of lifestyle changes and medications, with a focus on reducing morbidity, mortality, and improving quality of life, as recommended by the most recent guidelines 1.
Key Components of Heart Failure Treatment
- Lifestyle changes: limiting sodium intake to 2-3 grams daily, restricting fluid intake if advised, maintaining regular physical activity as tolerated, and monitoring daily weight.
- First-line medications: ACE inhibitors (like enalapril 2.5-20mg twice daily or lisinopril 10-40mg once daily) or ARBs if ACE inhibitors aren't tolerated, as supported by the 2009 ACC/AHA guidelines 1.
- Beta-blockers (such as carvedilol 3.125-25mg twice daily or metoprolol succinate 25-200mg daily) are added for most patients, with careful consideration of their initiation and titration, as outlined in the 2009 ACC/AHA guidelines 1.
- Diuretics like furosemide (20-80mg daily or twice daily) help manage fluid retention, with the goal of relieving symptoms and reducing extracellular fluid volume excess, as recommended in the 2009 ACC/AHA guidelines 1.
Additional Considerations
- For patients with reduced ejection fraction, SGLT2 inhibitors (dapagliflozin 10mg daily or empagliflozin 10mg daily) have shown mortality benefits, as noted in the 2012 ESC guidelines 1.
- Mineralocorticoid receptor antagonists (spironolactone 25-50mg daily) may be added for persistent symptoms, with careful monitoring of kidney function and electrolytes, as recommended in the 2009 ACC/AHA guidelines 1.
- Regular monitoring of kidney function, electrolytes, and symptoms is essential, with dose adjustments as needed, to ensure optimal treatment outcomes, as emphasized in the 2009 ACC/AHA guidelines 1.
- Advanced heart failure may require specialized therapies like implantable devices or transplantation, as outlined in the 2012 ESC guidelines 1.
From the Research
Heart Failure Treatment Options
- The treatment of heart failure with reduced ejection fraction (HFrEF) has seen significant advances in recent years, with various pharmacological options available 2, 3, 4, 5.
- According to a meta-analysis, SGLT2 inhibitors, ARNIs, and MRAs were associated with a significant decrease in the risk of HF hospitalization compared with placebo 2.
- Another study found that continued use of ACEi/ARBs in hospitalized patients with HFrEF was associated with lower 1-year mortality risk and lower 1-6-year mortality risk in those with heart failure preserved ejection fraction (HFpEF) 3.
Pharmacological Treatment
- The basic pharmacological treatment of patients with HFrEF consists of a combination of ACE inhibitors/angiotensin receptor-neprilysin inhibitor (ARNI), beta-blockers, mineralocorticoid receptor antagonists (MRA), and the SGLT2 inhibitors dapagliflozin or empagliflozin 4.
- Treatment initiation of all four drug classes should be fast and simultaneous, and the incremental use of combinations of SGLT2 inhibitors, ACE inhibitors or ARBs, and β-blockers may be associated with accumulative benefits in HF hospitalization 2, 4.
Heart Failure with Reduced Ejection Fraction (HFrEF)
- HFrEF occurs when the left ventricular ejection fraction (LVEF) is 40% or less and is accompanied by progressive left ventricular dilatation and adverse cardiac remodeling 5.
- Assessment for heart failure begins with obtaining a medical history and physical examination, and central to diagnosis are elevated natriuretic peptides and identification of left ventricular systolic dysfunction with LVEF of 40% or less as measured by echocardiography 5.
Chronic Kidney Disease (CKD) and Heart Failure
- CKD is a common comorbidity in patients with HFrEF, and the presence of CKD is associated with more severe heart failure and poor cardiovascular outcome 6.
- Most drug classes are safe and effective up to CKD stage 3B (eGFR minimum 30 mL/min/1.73 m2), but data are lacking on the safety and efficacy for any HFrEF therapies in CKD stage 5 (eGFR < 15 mL/min/1.73 m2 or dialysis) 6.