What is the initial therapy for congestive heart failure (CHF)?

Initial Therapy for Congestive Heart Failure (CHF)

The initial therapy for congestive heart failure should include an ACE inhibitor (or ARB if ACE inhibitor not tolerated), a beta-blocker, a diuretic for symptom relief, and an SGLT2 inhibitor, with careful monitoring of renal function and electrolytes.

First-Line Pharmacological Therapy

Core Medications for HFrEF (Heart Failure with Reduced Ejection Fraction)

1. ACE Inhibitors

   • Recommended for all patients with reduced ejection fraction (LVEF ≤40%) 1
   • Start with low dose and titrate up (e.g., lisinopril starting at 5-10 mg daily) 2
   • Monitor renal function and electrolytes 1-2 weeks after initiation and dose changes 1
   • For heart failure, start at 5 mg once daily with diuretics and digitalis 2

2. Beta-Blockers

   • Recommended for all stable patients with mild to severe heart failure and reduced LVEF 3, 1
   • Evidence-based options include metoprolol succinate, carvedilol, or bisoprolol 1
   • Start at low dose and gradually titrate up (e.g., metoprolol succinate 12.5-25 mg daily) 4
   • The MERIT-HF trial showed 34% reduction in all-cause mortality with metoprolol succinate 4

3. Diuretics

   • Essential for symptom relief in patients with fluid retention 3
   • Loop diuretics (e.g., furosemide) are preferred for most patients 3
   • Initial dose of furosemide 20-40 mg IV for new-onset CHF; for those on chronic therapy, initial IV dose should be at least equivalent to oral dose 3
   • Can be given as intermittent boluses or continuous infusion 3

4. SGLT2 Inhibitors

   • Add dapagliflozin or empagliflozin to reduce mortality and hospitalization 1
   • Monitor electrolytes and renal function regularly 1

Additional Therapies to Consider

1. Mineralocorticoid Receptor Antagonists (MRAs)

   • Recommended for patients with NYHA class III-IV symptoms and LVEF ≤35% 3, 1
   • Options include spironolactone or eplerenone 1
   • Close monitoring of potassium and renal function is essential 1

2. Angiotensin Receptor-Neprilysin Inhibitors (ARNIs)

   • Can replace ACE inhibitors in selected patients 1

3. ARBs

   • Alternative for patients who cannot tolerate ACE inhibitors 3, 1

Initiation and Titration Strategy

1. Start with ACE inhibitor and diuretic

   • Begin with low-dose ACE inhibitor (e.g., lisinopril 2.5-5 mg daily) 3, 2
   • Add diuretic for symptom relief of fluid overload 3
   • Review diuretic need and dose before starting ACE inhibitor 3
   • Consider reducing diuretics temporarily when initiating ACE inhibitor to minimize hypotension 3

2. Add beta-blocker after stabilization

   • Initiate at low dose once patient is euvolemic 3, 4
   • Gradually titrate up as tolerated 3

3. Add MRA for advanced heart failure

   • For patients with persistent symptoms despite optimal therapy with ACE inhibitor and beta-blocker 3

4. Add SGLT2 inhibitor

   • Add to the regimen regardless of diabetes status 1

Monitoring and Follow-up

1. Regular assessment of:

   • Symptoms, urine output, renal function, and electrolytes during diuretic use 3
   • Renal function and electrolytes 1-2 weeks after initiation or dose changes of ACE inhibitors, 3 months later, and then every 6 months 3, 1
   • Daily weight monitoring with instructions to adjust diuretics if weight increases by 1.5-2.0 kg over 2 days 1

2. Dose titration:

   • Aim for target doses used in clinical trials 1
   • Adjust based on blood pressure, heart rate, renal function, and symptoms

Lifestyle Modifications

1. Physical Activity

   • Regular aerobic exercise is recommended to improve functional capacity, symptoms, and reduce hospitalization risk 3, 5
   • Initially supervised exercise training is beneficial 3

2. Dietary Recommendations

   • Moderate sodium restriction for patients with severe heart failure 3, 1
   • Avoid excessive fluid intake in severe heart failure 3, 1
   • Limit alcohol consumption 3, 1

3. Self-monitoring

   • Daily weight monitoring 1
   • Recognition of worsening symptoms 1
   • Understanding when to adjust medications or seek medical attention 1

Common Pitfalls to Avoid

1. Medication-related

   • Failure to titrate medications to target doses used in clinical trials 1
   • Inadequate monitoring of renal function and electrolytes 1
   • Use of NSAIDs, which can worsen renal function and fluid retention 3, 1
   • Using non-dihydropyridine CCBs (verapamil, diltiazem) in patients with HFrEF 3

2. Management-related

   • Inadequate diuresis in patients with fluid overload 1
   • Not considering device therapy (ICD, CRT) in appropriate candidates 1
   • Failure to educate patients about self-management 1

By following this comprehensive approach to CHF management, focusing on evidence-based pharmacological therapy and appropriate lifestyle modifications, patients can experience improved symptoms, quality of life, and reduced morbidity and mortality.