What is the initial management for congestive heart failure (CHF) with reduced ejection fraction (HFrEF)?

From the Guidelines

The initial management of congestive heart failure (CHF) with reduced ejection fraction (HFrEF) should focus on a combination of lifestyle modifications and guideline-directed medical therapy (GDMT), including an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor-neprilysin inhibitor (ARNi), a beta-blocker, a mineralocorticoid receptor antagonist (MRA), and a sodium-glucose cotransporter-2 (SGLT2) inhibitor, as tolerated, to reduce morbidity, mortality, and improve quality of life 1.

Key Components of Initial Management

• Establishing the diagnosis of HFrEF and addressing congestion
• Initiating GDMT with ACE inhibitor or ARNi, beta-blocker, and MRA, as indicated
• Considering the addition of SGLT2 inhibitors, regardless of diabetes status
• Implementing lifestyle modifications, including sodium and fluid restriction, daily weight monitoring, and moderate physical activity
• Educating patients about medication adherence, symptom recognition, and when to seek medical attention for worsening symptoms

Medication Therapy

• ACE inhibitors, such as lisinopril or enalapril, should be started at a low dose and titrated to target dosing as tolerated
• Beta-blockers, such as carvedilol or metoprolol succinate, should be initiated at a low dose and titrated to target dosing as tolerated
• MRA, such as spironolactone, should be considered for patients with more severe symptoms (NYHA class II-IV)
• SGLT2 inhibitors, such as dapagliflozin or empagliflozin, should be considered regardless of diabetes status

Lifestyle Modifications

• Sodium restriction (<2-3 g/day)
• Fluid restriction (1.5-2 L/day)
• Daily weight monitoring
• Moderate physical activity

Ongoing Management

• Continue GDMT with serial reassessment and optimize dosing, adherence, and patient education
• Address goals of care and consider referral for HF specialty care as indicated
• Consider additional therapies, such as hydral-nitrates, implantable cardioverter-defibrillator (ICD), or cardiac resynchronization therapy (CRT), as indicated 1.

From the FDA Drug Label

The Systolic Heart Failure Treatment with the I f Inhibitor Ivabradine Trial (SHIFT) was a randomized, double-blind trial comparing ivabradine and placebo in 6,558 adult patients with stable New York Heart Association (NYHA) class II to IV heart failure, left ventricular ejection fraction ≤ 35%, and resting heart rate ≥ 70 bpm Patients had to have been clinically stable for at least 4 weeks on an optimized and stable clinical regimen, which included maximally tolerated doses of beta-blockers and, in most cases, ACE inhibitors or ARBs, spironolactone, and diuretics, with fluid retention and symptoms of congestion minimized.

The initial management for congestive heart failure (CHF) with reduced ejection fraction (HFrEF) includes:

• Optimized beta-blocker therapy: to reduce morbidity and mortality
• ACE inhibitors or ARBs: to reduce afterload and slow disease progression
• Diuretics: to manage fluid retention and symptoms of congestion
• Spironolactone: to reduce mortality and morbidity
• Ivabradine: may be considered in patients with a heart rate ≥ 70 bpm, despite optimal beta-blocker therapy, to reduce the risk of hospitalization for worsening heart failure 2
• Sacubitril and valsartan: may be considered as an alternative to ACE inhibitors or ARBs, to reduce the risk of hospitalization for worsening heart failure and cardiovascular death 3

From the Research

Initial Management of Congestive Heart Failure (CHF) with Reduced Ejection Fraction (HFrEF)

The initial management of CHF with reduced ejection fraction (HFrEF) involves a multifaceted approach that includes:

• Identification and treatment of underlying and precipitating causes of heart failure 4
• Use of diuretics as first-line drugs to treat volume overload 4, 5
• Administration of angiotensin-converting enzyme (ACE) inhibitors and β-blockers to improve symptoms and reduce morbidity and mortality 4, 6, 5
• Consideration of angiotensin II receptor blockers (ARBs) if patients are intolerant to ACE inhibitors 4
• Addition of an aldosterone antagonist in selected patients with class II-IV HF 4, 5

Disease-Modifying Therapies

Disease-modifying therapies play a crucial role in the management of HFrEF, including:

• Sacubitril/valsartan, which may be used instead of an ACE inhibitor or ARB in patients with chronic symptomatic HFrEF class II or III 4, 7
• Ivabradine, which can be used in selected patients with HFrEF 4, 5
• Isosorbide dinitrate plus hydralazine, which may be beneficial in African American patients with class II-IV HF 4
• Sodium-glucose cotransporter 2 (SGLT2) inhibitors, which have been shown to reduce cardiovascular and all-cause mortality in patients with HFrEF 5

Device Therapies

Device therapies, such as:

• Implantable cardioverter defibrillators, which can improve survival in patients with HFrEF 6, 7
• Cardiac resynchronization therapy, which can reduce mortality and morbidity in patients with interventricular dyssynchrony 6, 5
• Transcatheter mitral valve repair, which may be beneficial in patients with severe secondary mitral regurgitation 5