What are the treatment options for heart failure (congestive heart failure)?

From the Guidelines

Heart failure treatment should prioritize a comprehensive approach combining medications, lifestyle changes, and sometimes devices or surgery, with a focus on reducing morbidity, mortality, and improving quality of life. The cornerstone medications include ACE inhibitors or ARBs to reduce strain on the heart, beta-blockers to slow heart rate and reduce workload, and diuretics to reduce fluid retention. For patients with reduced ejection fraction, SGLT2 inhibitors have shown significant mortality benefits 1. Aldosterone antagonists may be added for moderate to severe heart failure.

Key Medications

• ACE inhibitors (like lisinopril 10-40mg daily) or ARBs (such as losartan 25-100mg daily)
• Beta-blockers (metoprolol succinate 25-200mg daily or carvedilol 3.125-25mg twice daily)
• Diuretics (furosemide 20-80mg daily)
• SGLT2 inhibitors (empagliflozin 10mg daily or dapagliflozin 10mg daily) for patients with reduced ejection fraction
• Aldosterone antagonists (spironolactone 25-50mg daily) for moderate to severe heart failure

Lifestyle Modifications

• Sodium restriction (<2g daily)
• Fluid restriction if needed
• Regular physical activity as tolerated
• Smoking cessation
• Limiting alcohol intake

Treatment Approach

Treatment should be individualized based on heart failure type (reduced vs. preserved ejection fraction), severity, and comorbidities, with regular monitoring of kidney function, electrolytes, and symptoms to adjust therapy as needed 1. The most recent guidelines suggest that inhibitors of the renin–angiotensin system, neprilysin inhibitors, beta-adrenergic blockers, and mineralocorticoid receptor antagonists are essential treatments for patients with chronic heart failure and a reduced ejection fraction 1.

From the FDA Drug Label

The precise mechanism for the beneficial effects of beta-blockers in heart failure has not been elucidated Clinical Trials MERIT-HF was a double-blind, placebo-controlled study of metoprolol succinate extended-release tablets conducted in 14 countries including the U.S. The trial was terminated early for a statistically significant reduction in all-cause mortality (34%, nominal p=0.00009). The risk of all-cause mortality plus all-cause hospitalization was reduced by 19% (p=0. 00012). Heart Failure Dosage must be individualized and closely monitored during up-titration. The recommended starting dose of metoprolol succinate extended-release tablets is 25 mg once daily for two weeks in patients with NYHA Class II heart failure and 12. 5 mg once daily in patients with more severe heart failure.

Heart Failure Treatment: Metoprolol succinate extended-release tablets are used in the treatment of heart failure. The dosage must be individualized and closely monitored during up-titration.

• The recommended starting dose is 25 mg once daily for two weeks in patients with NYHA Class II heart failure and 12.5 mg once daily in patients with more severe heart failure.
• The dose should then be doubled every two weeks to the highest dosage level tolerated by the patient or up to 200 mg of metoprolol succinate extended-release tablets 2.
• The MERIT-HF study showed a statistically significant reduction in all-cause mortality (34%) and a reduction in the risk of all-cause mortality plus all-cause hospitalization (19%) 2.

From the Research

Heart Failure Treatment Options

• The treatment of heart failure with reduced ejection fraction (HFrEF) has evolved with the introduction of new medical therapies, increasing treatment complexity 3.
• Expert consensus guidelines recommend sequential stepwise initiation and titration of medical therapy, which can be labour intensive 3.
• Four medication classes, including renin-angiotensin-neprilysin inhibitors, β-blockers, mineralocorticoid antagonists, and sodium-glucose cotransporter inhibitors, have been shown to confer rapid and robust reduction in morbidity and mortality in patients with HFrEF 3.

Pharmaceutical Therapies

• Angiotensin-converting-enzyme inhibitors (ACE inhibitors) and angiotensin II receptor antagonists (ARBs) are cornerstones in the treatment of HFrEF, with ACE inhibitors remaining the first-line option 4.
• ARBs have been shown to have haemodynamic effects similar to ACE inhibitors, but with differences in mechanism of action and adverse effects 4.
• The combination of ACE inhibitors and ARBs has not been associated with additional benefit over either one alone and may potentially be harmful 5.

Device-Based Therapies

• Implantable defibrillators and special pacemakers for cardiac resynchronization are well-established treatments for heart failure 6.
• The utility of alternative devices, such as baroreflex modulation or cardiac contractility modulation, needs to be investigated in further studies 6.
• Catheter-based treatment of secondary mitral regurgitation with a MitraClip has been shown to improve outcomes in selected patients 6.

Treatment Outcomes

• Continued use of ACE inhibitors and ARBs in hospitalized patients with HFrEF has been associated with lower 1-year mortality risk and reduced risk of hospitalizations 7.
• The effect size of ACE inhibitors and ARBs is lower among patients with heart failure preserved ejection fraction (HFpEF), with more heterogeneous outcomes 7.
• The use of neither ACE inhibitors nor ARBs has been associated with increased risk of mortality, hospitalization, and composite outcomes 5.