From the Guidelines
For managing Congestive Heart Failure (CHF), start with a combination of medications and lifestyle changes, prioritizing ACE inhibitors, beta-blockers, and diuretics, as recommended by the most recent guidelines 1. The key medications include:
- ACE inhibitors (e.g., lisinopril 10-40 mg daily) or ARBs (e.g., losartan 25-100 mg daily) to reduce blood pressure and workload on the heart.
- Beta-blockers (e.g., metoprolol succinate 25-200 mg daily) to slow heart rate and reduce strain.
- Diuretics (e.g., furosemide 20-80 mg daily) to reduce fluid retention.
- Aldosterone antagonists (e.g., spironolactone 25-50 mg daily) for advanced cases. Lifestyle modifications are crucial:
- Restrict sodium intake to less than 2,000 mg per day.
- Limit fluid intake to 1.5-2 liters daily.
- Engage in regular, moderate exercise as tolerated.
- Monitor daily weight and report gains of more than 2-3 pounds in a day.
- Quit smoking and limit alcohol consumption. Regular follow-ups with a cardiologist are essential for medication adjustments and monitoring of heart function, as emphasized in earlier guidelines 1. This regimen aims to reduce symptoms, improve quality of life, and slow disease progression by reducing the heart's workload and managing fluid balance. Some patients may also benefit from additional treatments, such as sacubitril/valsartan, ivabradine, or hydralazine and isosorbide dinitrate, as recommended in the 2016 ESC guidelines 1. Patient education is also essential, including understanding the cause of heart failure, recognizing signs and symptoms, and maintaining good glucose control if diabetic, as outlined in the 2008 ESC guidelines 1.
From the Research
Symptoms of Congestive Heart Failure (CHF)
- Fatigue and dyspnoea are the predominant symptoms of patients with CHF 2
- Fatigue is thought to result from changes in peripheral muscle metabolism secondary to decreased vasodilative capacity and physical inactivity 2
- Dyspnoea results from acute pulmonary congestion due to backward failure, and increased physiological dead space ventilation caused by pulmonary ventilation/perfusion mismatch 2
Treatment Options for CHF
- Pharmacological management of chronic systolic heart failure includes therapy with angiotensin-converting enzyme inhibitors, beta-blockers, and diuretics 3
- Digoxin is added to improve clinical symptoms, especially in patients with atrial fibrillation 3, 4
- Aldosterone antagonists may be recommended in select patients with stable New York Heart Association class III or IV heart failure 3
- Nonpharmacologic interventions include sodium and fluid restriction, a balance of rest and physical activity, hemofiltration, and peritoneal dialysis 5
- Mechanical support from intraaortic balloon counterpulsation and ventricular assist devices has improved survival in certain high-risk patients 5
- Cardiac transplantation offers new hope for patients refractory to conventional therapies 5
- Initial pharmacotherapy for systolic heart failure should consist of maximal tolerated dosages of ACE inhibitors, ARBs if ACE inhibitors are not tolerated, and adequate dosages of hydralazine and isosorbide dinitrate if ACE inhibitors or ARBs are not tolerated 4
- Recent therapies afforded to assist heart failure patients include mechanical circulatory support (MCS), neprilysin inhibitors, and chronic resynchronization therapy (CRT) 6