What is the recommended treatment for congestive heart failure?

Congestive Heart Failure Treatment

The cornerstone treatment for congestive heart failure includes four foundational medications: ACE inhibitors/ARNIs, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors, which should be initiated in a stepwise manner based on ejection fraction and symptom severity to reduce mortality and hospitalizations. 1

First-Line Pharmacological Therapy

ACE Inhibitors

• Start with low doses and titrate to target doses used in clinical trials 2, 1
• Options include Captopril, Enalapril, Lisinopril, Ramipril, and Trandolapril 1
• Monitor blood pressure, renal function, and electrolytes at 1-2 weeks after each dose increment, at 3 months, and every 6 months thereafter 2, 1
• Contraindications: history of angioedema, bilateral renal artery stenosis, pregnancy

Beta-Blockers

• Initiate along with ACE inhibitors in stable patients (NYHA class II-IV) 2, 1
• Only three beta-blockers have proven mortality benefits 2:
  • Bisoprolol: Start 1.25 mg once daily, target 10 mg once daily
  • Carvedilol: Start 3.125 mg twice daily, target 25-50 mg twice daily
  • Metoprolol CR/XL: Start 12.5-25 mg once daily, target 200 mg once daily
• Titrate slowly: double dose at not less than 2-week intervals 2
• Cautions: severe (NYHA class IV) CHF, recent exacerbation, heart block, heart rate <60/min 2

Mineralocorticoid Receptor Antagonists (MRAs)

• Add for patients who remain symptomatic despite ACE inhibitor and beta-blocker therapy 2, 1
• Options: spironolactone or eplerenone 1
• Monitor potassium and renal function closely, especially when combined with ACE inhibitors 2

SGLT2 Inhibitors

• Add Dapagliflozin or Empagliflozin to reduce risk of heart failure hospitalization and cardiovascular death 1
• Beneficial regardless of diabetes status 1

Diuretics for Symptom Management

• Loop diuretics (furosemide) or thiazides for fluid overload 2, 1
• If insufficient response:
  • Increase diuretic dose
  • Combine loop diuretics and thiazides
  • For persistent fluid retention: administer loop diuretics twice daily 2
• Patients should weigh themselves daily and increase diuretic dose if weight increases by 1.5-2.0 kg over 2 days 2, 1

Advanced Pharmacological Options

Angiotensin Receptor-Neprilysin Inhibitor (ARNI)

• Sacubitril/valsartan is superior to ACE inhibitors alone in reducing cardiovascular death and heart failure hospitalization 3
• Consider switching from ACE inhibitor to ARNI in patients who remain symptomatic despite optimal therapy 1, 3
• Requires 36-hour washout period after discontinuing ACE inhibitor 3

Angiotensin II Receptor Blockers (ARBs)

• Alternative for patients who cannot tolerate ACE inhibitors 2, 1
• May be used in combination with ACE inhibitors to improve symptoms and reduce hospitalizations 2, 4

Cardiac Glycosides (Digoxin)

• Indicated for atrial fibrillation with heart failure to control ventricular rate 2
• May improve symptoms in patients with persistent heart failure despite standard therapy 2
• Usual daily dose: 0.125-0.25 mg (elderly) to 0.25-0.375 mg if normal renal function 2

Device Therapy and Advanced Care

• Consider Implantable Cardioverter-Defibrillator (ICD) for patients with LVEF ≤35% and NYHA Class II-III symptoms 1
• Cardiac Resynchronization Therapy (CRT) for patients with LVEF ≤35%, QRS duration ≥150ms with LBBB morphology 1
• Advanced therapies (mechanical circulatory support, heart transplantation) for end-stage disease 1

Monitoring and Follow-up

• Regular monitoring of electrolytes and renal function is essential 2, 1
• Check blood pressure, renal function, and electrolytes:
  • 1-2 weeks after each dose increment
  • 3 months after initiation
  • Every 6 months thereafter 2, 1
• Avoid NSAIDs due to risk of worsening renal function and fluid retention 1

Treatment Algorithm

1. Initial Diagnosis and Assessment:

   • Confirm heart failure diagnosis with echocardiography or other imaging
   • Determine ejection fraction (HFrEF vs. HFpEF)
   • Assess NYHA functional class

2. Start Foundation Therapy (for HFrEF):

   • ACE inhibitor (or ARB if intolerant)
   • Beta-blocker (if stable)
   • Diuretic (if fluid overload present)

3. Optimize Foundation Therapy:

   • Titrate ACE inhibitor and beta-blocker to target doses
   • Add MRA if patient remains symptomatic
   • Add SGLT2 inhibitor

4. Consider Advanced Options if patient remains symptomatic:

   • Switch from ACE inhibitor to ARNI
   • Add digoxin (especially with atrial fibrillation)
   • Evaluate for device therapy (ICD/CRT)
   • Consider advanced therapies for end-stage disease

5. Ongoing Monitoring:

   • Regular assessment of symptoms, vital signs, weight
   • Laboratory monitoring of electrolytes and renal function
   • Adjust diuretics based on fluid status

The quadruple therapy with ARNI, beta-blocker, MRA, and SGLT2 inhibitor provides the largest reduction in cardiovascular death and heart failure hospitalization 1.