What are the initial pharmacological and non-pharmacological recommendations for managing Congestive Heart Failure (CHF)?

From the Guidelines

The initial management of Congestive Heart Failure (CHF) should prioritize pharmacological therapies including ACE inhibitors, beta-blockers, and diuretics, alongside non-pharmacological approaches such as sodium and fluid restriction, daily weight monitoring, and regular physical activity, as supported by the most recent guidelines 1.

Pharmacological Management

The cornerstone of CHF management involves the use of several key pharmacological agents. These include:

• ACE inhibitors (e.g., lisinopril 5-40 mg daily or enalapril 2.5-20 mg twice daily) or ARBs (e.g., losartan 25-100 mg daily) if ACE inhibitors are not tolerated, as recommended by guidelines 1.
• Beta-blockers (e.g., metoprolol succinate 12.5-200 mg daily or carvedilol 3.125-25 mg twice daily) should be initiated at low doses and gradually titrated up, given their proven benefit in reducing mortality and morbidity in CHF patients 1.
• Diuretics (e.g., furosemide 20-80 mg daily or twice daily) are essential for managing fluid overload, a common symptom in CHF patients 1.
• For patients with moderate to severe CHF, aldosterone antagonists (e.g., spironolactone 12.5-25 mg daily) may be added to further reduce morbidity and mortality 1.

Non-Pharmacological Management

Non-pharmacological interventions are also crucial in the management of CHF. These include:

• Sodium restriction to 2-3 grams daily and fluid restriction to 1.5-2 liters daily to prevent fluid overload.
• Daily weight monitoring to quickly identify any signs of fluid retention.
• Regular physical activity as tolerated to improve cardiac function and overall health.
• Smoking cessation, given the detrimental effects of smoking on cardiovascular health.

Recent Guidelines and Recommendations

Recent guidelines, such as those from the European Society of Cardiology 1, emphasize the importance of evidence-based pharmacotherapy, including the use of SGLT2 inhibitors for certain patients with heart failure with reduced ejection fraction, in addition to the traditional therapies like ACE inhibitors, ARBs, beta-blockers, and mineralocorticoid receptor antagonists. The selection of specific medications and the implementation of non-pharmacological strategies should be tailored to the individual patient's needs and clinical status, with a focus on improving quality of life, reducing morbidity, and decreasing mortality 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 Valsartan Heart Failure Trial (Val-HeFT) was a multinational, double-blind study in which 5,010 patients with NYHA class II (62%) to IV (2%) heart failure and LVEF less than 40%, on baseline therapy chosen by their physicians, were randomized to placebo or valsartan

The initial pharmacological recommendations for managing Congestive Heart Failure (CHF) include:

• Angiotensin II receptor blockers (ARBs): Valsartan has been shown to reduce the risk of heart failure morbidity in patients not receiving an ACE inhibitor 2
• Angiotensin receptor-neprilysin inhibitors (ARNIs): Sacubitril and valsartan has been shown to be 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) 3 Non-pharmacological recommendations are not directly addressed in the provided drug labels. Key points to consider when managing CHF include:
• NYHA classification: Patients with NYHA class II-IV heart failure may benefit from treatment with ARBs or ARNIs
• Left ventricular ejection fraction (LVEF): Patients with LVEF less than 40% may benefit from treatment with ARBs or ARNIs
• Concomitant medications: Patients receiving beta-blockers, mineralocorticoid antagonists, and diuretics may still benefit from treatment with ARBs or ARNIs 3

From the Research

Initial Pharmacological Recommendations for CHF Management

• Diuretics are the first-line drugs in the treatment of patients with HFrEF and volume overload 4
• Angiotensin-converting enzyme (ACE) inhibitors and β-blockers (carvedilol, sustained-release metoprolol succinate, or bisoprolol) should be used in treatment of HFrEF 4
• Use an angiotensin II receptor blocker (ARB) (candesartan or valsartan) if intolerant to ACE inhibitors because of cough or angioneurotic edema 4
• Sacubitril/valsartan may be used instead of an ACE inhibitor or ARB in patients with chronic symptomatic HFrEF class II or III to further reduce morbidity and mortality 4, 5
• Add an aldosterone antagonist (spironolactone or eplerenone) in selected patients with class II-IV HF who can be carefully monitored for renal function and potassium concentration 4
• Add isosorbide dinitrate plus hydralazine in patients self-described as African Americans with class II-IV HF being treated with diuretics, ACE inhibitors, and β-blockers 4
• Ivabradine can be used in selected patients with HFrEF 4
• Dapagliflozin, a medication targeting the sodium-glucose cotransporter 2 (SGLT2), can be used in addition to current therapies 5
• SGLT2 inhibitors were the optimal drug class for HFpEF and HFmrEF, consistent with the most recent guideline recommendation 6

Non-Pharmacological Recommendations for CHF Management

• Underlying and precipitating causes of heart failure (HF) with reduced left ventricular ejection fraction (HFrEF) should be identified and treated when possible 4
• Hypertension should be treated 4
• Patient education on lifestyle modifications, such as diet and exercise, is important for CHF management, although specific details are not provided in the referenced studies

Individualizing Treatment for CHF Patients

• HF therapy must be adapted to the clinical profile (i.e. congestion, blood pressure, heart rate, renal function, and electrolytes) 7
• Blood pressure is reduced by beta blockers, renin-angiotensin-aldosterone system inhibitors, sacubitril/valsartan, and, minimally, by SGLT2 inhibitors and vericiguat 7
• Heart rate decreases with beta blockers and ivabradine 7
• Renal function is impaired and potassium levels are increased with renin-angiotensin-aldosterone system inhibitors and sacubitril/valsartan 7