What is the recommended treatment for congestive heart failure?

Treatment of Congestive Heart Failure

The recommended first-line treatment for congestive heart failure includes ACE inhibitors and beta-blockers for patients with reduced ejection fraction (HFrEF), with diuretics added for symptom relief when fluid overload is present. 1, 2

Initial Assessment and Classification

• Confirm heart failure with reduced ejection fraction (EF <40-45%)
• Determine NYHA functional class (I-IV)
• Assess for signs of fluid overload (edema, raised jugular venous pressure, dyspnea)

First-Line Pharmacological Therapy

ACE Inhibitors

• Start with low dose and titrate upward

• Target doses:

  ACE Inhibitor	Starting dose	Target dose
  Lisinopril	2.5-5.0 mg once daily	30-35 mg once daily
  Enalapril	2.5 mg twice daily	10-20 mg twice daily
  Ramipril	2.5 mg once daily	5 mg twice daily or 10 mg once daily
  Captopril	6.25 mg three times daily	50-100 mg three times daily
  Trandolapril	1.0 mg once daily	4 mg once daily

• Monitor blood chemistry (urea, creatinine, K+) and blood pressure 1-2 weeks after initiation and each dose increase 1

• Higher doses of ACE inhibitors have shown greater benefits in reducing mortality and hospitalizations compared to lower doses 3, 4

Beta-Blockers

• Add once patient is stable on ACE inhibitor therapy

• Only use evidence-based beta-blockers:

  Beta-blocker	Starting dose	Target dose
  Bisoprolol	1.25 mg once daily	10 mg once daily
  Carvedilol	3.125 mg twice daily	25-50 mg twice daily
  Metoprolol CR/XL	12.5-25 mg once daily	200 mg once daily

• Start with low dose and double at 2-week intervals

• Do not initiate during acute decompensation 1

• Continue even if symptomatic improvement is slow (may take 3-6 months)

Additional Therapies Based on Severity

Diuretics

• Use for symptom relief when fluid overload is present
• Loop diuretics (e.g., furosemide) preferred for GFR <30 ml/min
• Thiazides can be used if GFR >30 ml/min or added to loop diuretics for resistant edema 1

Aldosterone Antagonists (MRAs)

• Add for patients with NYHA class III-IV symptoms despite optimal therapy
• Spironolactone has been shown to improve survival in advanced heart failure 1
• Monitor potassium and renal function closely

Angiotensin Receptor Blockers (ARBs)

• Use in patients who cannot tolerate ACE inhibitors (e.g., due to cough)
• May be added to ACE inhibitors to improve symptoms and reduce hospitalizations 1

Cardiac Glycosides

• Consider digoxin for patients with persistent symptoms despite standard therapy
• Particularly beneficial in patients with atrial fibrillation 1

Newer Therapies

• Sacubitril/valsartan (ARNI) has demonstrated superiority to enalapril in reducing cardiovascular death and heart failure hospitalization 5

Monitoring and Follow-up

• Check renal function and electrolytes:
  • Before starting therapy
  • 1-2 weeks after each dose increase
  • At 3 months after stabilization
  • Every 6 months thereafter

Common Pitfalls and Management

Worsening Renal Function

• An increase in creatinine up to 50% above baseline or to 3 mg/dl (266 μmol/l) is acceptable
• If greater increases occur:
  1. Stop nephrotoxic drugs (e.g., NSAIDs)
  2. Consider reducing diuretic dose if no congestion
  3. If necessary, halve ACE inhibitor dose and recheck 1

Hypotension

• Asymptomatic hypotension: usually requires no change in therapy
• Symptomatic hypotension:
  1. Reconsider need for nitrates, calcium channel blockers
  2. Reduce diuretic dose if no congestion
  3. If persistent, consider reducing ACE inhibitor dose 1

Cough with ACE Inhibitors

• Confirm it's not due to pulmonary edema
• If truly ACE inhibitor-related and intolerable, switch to an ARB 1

Beta-Blocker Intolerance

• If worsening symptoms occur:
  1. Increase diuretic dose if congestion present
  2. Halve beta-blocker dose if necessary
  3. Never stop beta-blockers abruptly unless absolutely necessary 1

By following this evidence-based approach to heart failure management, focusing on ACE inhibitors and beta-blockers as cornerstone therapies with appropriate adjunctive treatments based on symptom severity, both mortality and morbidity can be significantly reduced while improving quality of life.