What is the recommended treatment for congestive heart failure?

Treatment of Congestive Heart Failure

The recommended first-line treatment for congestive heart failure with reduced ejection fraction includes an ACE inhibitor (or ARB if ACE inhibitor not tolerated) in combination with a beta-blocker and diuretics when fluid overload is present. 1

Initial Assessment and Classification

• Confirm heart failure with reduced ejection fraction (HFrEF) - defined as EF <40-45%
• Determine NYHA functional class (I-IV) to guide therapy intensity
• Assess for fluid overload requiring diuretic therapy

First-Line Pharmacological Therapy

ACE Inhibitors

• Start with low dose and titrate up to target dose
• For lisinopril, start at 5 mg daily for heart failure, with a target of 20-40 mg daily 2
• Lower starting dose (2.5 mg) for patients with hyponatremia or hypotension 2
• Monitor renal function and electrolytes:
  • Before starting therapy
  • 1-2 weeks after each dose increase
  • At 3 months
  • Every 6 months thereafter 1

Diuretics

• Loop diuretics (e.g., furosemide) or thiazides are recommended
• Use thiazides only if GFR >30 mL/min 3
• For insufficient response:
  • Increase diuretic dose
  • Consider combining loop diuretics and thiazides
  • For persistent fluid retention, administer loop diuretics twice daily 3

Beta-Blockers

• Recommended for all stable patients with HFrEF (NYHA II-IV) already on ACE inhibitors and diuretics 3
• Start only when patient is relatively stable without need for intravenous inotropic therapy 3
• Begin with very low dose and titrate gradually:
  • Bisoprolol: start 1.25 mg, target 10 mg daily
  • Metoprolol succinate: start 12.5-25 mg, target 200 mg daily
  • Carvedilol: start 3.125 mg, target 50 mg daily
  • Nebivolol: start 1.25 mg, target 10 mg daily 3

Additional Therapies Based on Disease Severity

For Advanced Heart Failure (NYHA III-IV)

• Add aldosterone antagonists (e.g., spironolactone) to ACE inhibitors and diuretics 3, 1
• Use with caution and monitor potassium levels closely
• Start with low dose and titrate according to potassium levels

For Patients with Atrial Fibrillation

• Cardiac glycosides (digoxin) are particularly indicated 3
• Usual daily dose: 0.125-0.25 mg (0.0625-0.125 mg in elderly) 3
• Contraindicated in bradycardia, AV blocks, sick sinus syndrome 3

For ACE Inhibitor Intolerance

• ARBs are recommended as an alternative with similar efficacy 3, 1
• Side effects, notably cough, are significantly less than with ACE inhibitors 3

Monitoring and Follow-up

• Monitor blood pressure, renal function, and electrolytes:
  • 1-2 weeks after initiation
  • After each dose increase
  • At 3 months
  • Every 6 months thereafter 1
• Assess for symptomatic improvement and signs of fluid retention

Potential Pitfalls and Precautions

• Avoid NSAIDs in patients on ACE inhibitors/ARBs 3, 1
• Avoid potassium-sparing diuretics when initiating ACE inhibitor therapy 3
• If hypotension occurs with beta-blockers, first reduce vasodilator doses before reducing beta-blocker dose 3
• For worsening heart failure during beta-blocker titration, increase diuretics or ACE inhibitors before reducing beta-blocker dose 3
• If inotropic support is needed in patients on beta-blockers, phosphodiesterase inhibitors are preferred 3

The evidence strongly supports this stepwise approach to heart failure management, with studies showing improvements in both mortality and morbidity outcomes when following these guidelines 4. High-dose lisinopril has demonstrated better outcomes than low-dose therapy in reducing hospitalizations and major clinical events 4.