What is the initial management for patients with heart failure as indicated by an European Heart Rhythm Association (EHRA) score?

Initial Management of Heart Failure Based on EHRA Score

For patients with heart failure, the initial management should include ACE inhibitors as first-line therapy, particularly in patients with reduced left ventricular systolic function (LVEF <40-45%), with or without symptoms. 1

Pharmacological Management Algorithm

First-Line Therapy

• ACE inhibitors: Start at low dose and titrate to target doses shown effective in clinical trials 1
  • For patients without fluid retention: ACE inhibitors alone
  • For patients with fluid retention: ACE inhibitors plus diuretics 1

Dosing Recommendations

1. Initial dosing: Start at lower dose level (e.g., enalapril 2.5 mg twice daily) 2
2. Titration: Gradually increase to target doses used in clinical trials 1
3. Target doses: Aim for doses proven effective in heart failure trials (e.g., enalapril 10-20 mg twice daily) 2

Monitoring During ACE Inhibitor Initiation

• Monitor renal function:
  • Before starting therapy
  • 1-2 weeks after each dose increment
  • Every 3-6 months during maintenance therapy 1
• Additional monitoring for patients with:
  • Past/present renal dysfunction
  • Electrolyte disturbances
  • When adding other medications affecting renal function 1

Additional Therapies Based on Clinical Status

For Fluid Overload

• Loop diuretics, thiazides, or metolazone: Essential for symptomatic treatment when pulmonary congestion or peripheral edema is present 1
  • Initial dose for new-onset heart failure: 20-40 mg IV furosemide (or equivalent) 1
  • For patients on chronic diuretic therapy: Initial IV dose at least equivalent to oral dose 1

For Patients Remaining Symptomatic Despite ACE Inhibitors

• Beta-blockers: Add after ACE inhibitor optimization 3
• Mineralocorticoid receptor antagonists (MRAs): For patients who remain symptomatic despite ACE inhibitor and beta-blocker therapy 1
• Sacubitril/valsartan: Consider as replacement for ACE inhibitor in patients who remain symptomatic despite optimal treatment with ACE inhibitor, beta-blocker, and MRA 1, 4

Special Considerations

Contraindications to ACE Inhibitors

• Bilateral renal artery stenosis
• History of angioedema with previous ACE inhibitor therapy 1
• For patients who develop cough or angioedema on ACE inhibitors, angiotensin receptor blockers (ARBs) are an effective alternative 1

Medications to Avoid

• Non-dihydropyridine calcium channel blockers (diltiazem, verapamil): Contraindicated as they increase risk of heart failure worsening 1, 3
• NSAIDs or COX-2 inhibitors: Not recommended as they increase risk of heart failure worsening 1
• Thiazolidinediones (glitazones): Not recommended due to increased risk of heart failure worsening 1

Device Therapy Considerations

For patients with persistent symptoms despite optimal medical therapy:

• ICD: Consider for patients with LVEF ≤35% despite 3 months of optimal medical therapy 1
• CRT: Consider for symptomatic patients with QRS duration ≥130 ms and LBBB QRS morphology 1

Common Pitfalls to Avoid

1. Titrating ACE inhibitors based only on symptomatic improvement rather than to target doses 1
2. Failing to monitor renal function and electrolytes during ACE inhibitor initiation and dose adjustments
3. Using calcium channel blockers like diltiazem or verapamil in heart failure patients 1
4. Delaying initiation of ACE inhibitors in asymptomatic patients with documented left ventricular systolic dysfunction 1
5. Implanting ICD within 40 days of myocardial infarction (not recommended) 1

The European Society of Cardiology guidelines emphasize the importance of early initiation of evidence-based therapies to improve survival, reduce hospitalizations, and enhance quality of life in patients with heart failure.