What is the first medication to add for a patient diagnosed with systolic heart failure after treatment for acute exacerbation?

From the Guidelines

The first medication to add for a patient diagnosed with systolic heart failure after treatment for acute exacerbation is typically an ACE inhibitor, such as enalapril, lisinopril, or captopril, as recommended by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. These medications should be initiated at a low dose and gradually titrated upward as tolerated. For example, enalapril might start at 2.5 mg twice daily and be increased every 2 weeks toward a target dose of 10-20 mg twice daily. ACE inhibitors reduce mortality and morbidity in heart failure patients by counteracting the renin-angiotensin-aldosterone system, reducing afterload, and preventing ventricular remodeling. They also help reduce the risk of heart failure hospitalization and death. Patients should be monitored for potential side effects including hypotension, renal dysfunction, and hyperkalemia during initiation and dose titration. If ACE inhibitors are contraindicated or not tolerated, other guideline-directed medical therapies like ARBs or ARNi should be considered as alternative first-line agents. Some key points to consider when initiating ACE inhibitors include:

• Starting with a low dose and titrating upward as tolerated
• Monitoring for potential side effects such as hypotension and renal dysfunction
• Adjusting the dose based on the patient's response and tolerance
• Considering alternative agents if ACE inhibitors are contraindicated or not tolerated
• Using the medication in combination with other guideline-directed therapies, such as beta-blockers and mineralocorticoid receptor antagonists, to achieve optimal outcomes. The 2022 AHA/ACC/HFSA guideline provides a comprehensive overview of the management of heart failure, including the use of ACE inhibitors and other medications 1. Additionally, other studies have also supported the use of ACE inhibitors in the management of heart failure, including the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. Overall, the use of ACE inhibitors is a crucial component of the management of systolic heart failure, and should be initiated in a timely and appropriate manner to achieve optimal outcomes.

From the FDA Drug Label

In patients at risk for excessive hypotension, therapy should be started under very close medical supervision and such patients should be followed closely for the first two weeks of treatment and whenever the dose of enalapril and/or diuretic is increased Patients with heart failure given enalapril maleate commonly have some reduction in blood pressure, especially with the first dose, but discontinuation of therapy for continuing symptomatic hypotension usually is not necessary when dosing instructions are followed; caution should be observed when initiating therapy

The first medication to add for a patient diagnosed with systolic heart failure after treatment for acute exacerbation is enalapril, an ACE inhibitor, which should be started under close medical supervision due to the risk of excessive hypotension 2.

From the Research

First Medication for Systolic Heart Failure

The first medication to add for a patient diagnosed with systolic heart failure after treatment for acute exacerbation is typically an angiotensin-converting enzyme inhibitor (ACEI) or a beta-blocker.

• According to 3, the basis of modern chronic heart failure (CHF) treatment is a combination of optimum doses of a beta-blocker and an ACEI.
• The study 3 also mentions that by tradition and according to guideline recommendations, an ACEI is usually initiated first, followed by a beta-blocker after a varying time period based on clinical judgement.
• However, 3 notes that early beta-blockade has several theoretical advantages, and two surrogate end point studies have indicated that initiation of CHF treatment with a beta-blocker may be superior to an ACEI.

Considerations for Initiating Therapy

When initiating therapy for systolic heart failure, the following considerations should be taken into account:

• 4 suggests that ACE inhibitors have been shown to be effective in reducing the morbidity and mortality of patients with left ventricular systolic dysfunction.
• 5 recommends that patients with HF and an abnormal left ventricular ejection fraction (LVEF) (systolic heart failure) should be treated with diuretics if fluid retention is present; with an ACE inhibitor or an angiotensin receptor blocker if the patient cannot tolerate an ACE inhibitor.
• 6 notes that ACE inhibitors have significantly decreased cardiovascular mortality, myocardial infarction (MI), and hospitalizations for heart failure (HF) in patients with asymptomatic or symptomatic left ventricular (LV) systolic dysfunction.
• 7 warns that converting enzyme inhibitors should be administered initially under strict medical supervision with appropriate facilities available for dealing with occasional profound hypotension.