What medications should be given to a patient with suspected heart failure?

Medications for Suspected Heart Failure

For patients with suspected heart failure, first-line medications should include ACE inhibitors, beta-blockers, and diuretics, with additional therapies added based on symptom severity and ejection fraction. 1

Foundation Therapy

First-Line Medications

• ACE inhibitors: Start with low doses and titrate to target doses

  • Examples: Lisinopril, Enalapril, Ramipril
  • Contraindications: Pregnancy, history of angioedema, bilateral renal artery stenosis
  • Monitor: Renal function, potassium levels, blood pressure 2, 1

• Beta-blockers: Initiate after patient is stabilized on ACE inhibitors

  • Preferred agents: Carvedilol, Metoprolol succinate, Bisoprolol
  • Start at low dose (e.g., metoprolol succinate 25 mg daily) and double every 2 weeks as tolerated 1, 3
  • Target heart rate: 50-60 bpm 2
  • Monitor: Heart rate, blood pressure, signs of worsening heart failure

• Diuretics: For patients with fluid overload

  • Loop diuretics (e.g., furosemide) are preferred for acute symptom relief
  • Dosage should be adjusted based on symptoms and clinical status 2
  • Monitor: Electrolytes, renal function, urine output 2

For Patients with ARB Intolerance

• Hydralazine and isosorbide dinitrate: Alternative for patients who cannot take ACE inhibitors 2
  • Particularly beneficial in African American patients 4

Second-Line Therapy (for persistent symptoms)

• Mineralocorticoid Receptor Antagonists (MRAs):

  • Add spironolactone or eplerenone for patients with NYHA Class III-IV symptoms despite optimal therapy 2, 1
  • Start at low dose and monitor potassium and renal function carefully

• SGLT2 inhibitors:

  • Add as part of comprehensive therapy for HFrEF 1
  • Monitor for urinary tract infections and genital mycotic infections

• Digoxin:

  • Consider for patients with persistent symptoms despite optimal therapy
  • Particularly useful for patients with atrial fibrillation and rapid ventricular rates 2, 1
  • Target serum concentration <1 ng/mL 4

• Angiotensin Receptor-Neprilysin Inhibitors (ARNIs):

  • Consider replacing ACE inhibitor with sacubitril/valsartan after patient is stabilized on beta-blocker therapy 1
  • Superior to ACE inhibitors alone in reducing mortality and hospitalization

Management of Acute Decompensation

• Intravenous diuretics:

  • Initial dose: 20-40 mg IV furosemide for new-onset HF; at least equivalent to oral dose for chronic HF patients 2
  • Can be given as intermittent boluses or continuous infusion 2
  • Monitor urine output, renal function, and electrolytes regularly

• Temporary inotropic support (for cardiogenic shock or severe symptoms):

  • Low-dose dobutamine (2-5 μg/kg/min) or milrinone for short periods 2
  • Caution: Inotropes are not recommended unless the patient is symptomatically hypotensive or hypoperfused 2

Common Pitfalls to Avoid

• Avoid calcium channel blockers in HF with reduced ejection fraction unless needed for comorbid conditions like angina or hypertension 2
• Avoid NSAIDs and COX-2 inhibitors as they increase risk of HF worsening 2, 1
• Avoid thiazolidinediones (glitazones) as they increase risk of HF worsening 2
• Avoid stopping beta-blockers abruptly due to risk of rebound ischemia and arrhythmias 2
• Avoid excessive diuresis before ACE inhibitor initiation as it may lead to renal dysfunction or hypotension 1

Monitoring Recommendations

• Check electrolytes and renal function 1-2 weeks after initiation or dose changes, then at 3 months and every 6 months thereafter 1
• Monitor for signs of worsening heart failure: increased dyspnea, fatigue, edema, weight gain 2
• Evaluate improvement in symptoms and ejection fraction after 3 months of optimized therapy 1
• Patients should weigh themselves daily and increase diuretic dose if weight increases by 1.5-2.0 kg over 2 days 2

By following this medication algorithm and monitoring parameters, you can effectively manage patients with suspected heart failure to reduce mortality, hospitalizations, and improve quality of life.