What is the recommended treatment for a patient with Congestive Heart Failure (CHF)?

Treatment of Congestive Heart Failure (CHF)

The cornerstone of CHF treatment includes ACE inhibitors, beta blockers, diuretics, and mineralocorticoid receptor antagonists, with device therapy and SGLT2 inhibitors for appropriate patients. 1, 2

First-Line Pharmacological Therapy

ACE Inhibitors

• Class I, Level A recommendation for all patients with reduced ejection fraction (HFrEF) 1
• Start with low doses and titrate up to target doses
• Monitor renal function and electrolytes after initiation and with dose changes
• Contraindications: history of angioedema, bilateral renal artery stenosis, pregnancy

Beta Blockers

• Class I, Level A recommendation for all patients with current or prior symptoms of HFrEF 1
• Use only the three beta blockers proven to reduce mortality:
  • Bisoprolol
  • Carvedilol
  • Sustained-release metoprolol succinate
• Start at low dose and gradually titrate every 1-2 weeks
• Initiate after patient is stabilized on ACE inhibitor therapy

Diuretics

• Class I, Level C recommendation for patients with fluid retention 1
• Loop diuretics (first choice):
  • Furosemide: 20-40 mg once or twice daily (max 600 mg/day)
  • Bumetanide: 0.5-1.0 mg once or twice daily (max 10 mg/day)
  • Torsemide: 10-20 mg once daily (max 200 mg/day)
• For resistant cases, add thiazide diuretic (sequential nephron blockade):
  • Metolazone: 2.5-10 mg once daily
  • Hydrochlorothiazide: 25-100 mg once or twice daily
• Monitor electrolytes, renal function, and daily weights

Mineralocorticoid Receptor Antagonists (MRAs)

• Recommended for patients with NYHA class III-IV symptoms and LVEF ≤35% 2
• Options:
  • Spironolactone: 12.5-25 mg once daily (max 50 mg/day)
  • Eplerenone: alternative option with fewer hormonal side effects
• Monitor potassium and renal function closely

Second-Line or Alternative Therapies

Angiotensin Receptor Blockers (ARBs)

• Class I, Level A recommendation for patients intolerant to ACE inhibitors 1
• Class IIa, Level A recommendation as alternatives to ACE inhibitors 1
• Options include:
  • Candesartan: 4-32 mg daily
  • Valsartan: 80-320 mg daily
  • Losartan: 50-100 mg daily 1

Sacubitril/Valsartan (ARNI)

• Superior to ACE inhibitors in reducing cardiovascular death and heart failure hospitalization (HR 0.80; 95% CI, 0.73-0.87) 3
• Consider for patients with persistent symptoms despite optimal therapy
• Contraindicated with concurrent ACE inhibitor use (requires 36-hour washout period)

SGLT2 Inhibitors

• Add dapagliflozin or empagliflozin to reduce mortality and hospitalization 2
• Monitor electrolytes and renal function

Device Therapy

Implantable Cardioverter-Defibrillator (ICD)

• Reasonable for patients with asymptomatic ischemic cardiomyopathy who are ≥40 days post-MI with LVEF ≤30% on guideline-directed medical therapy 1, 2
• Recommended for patients with LVEF ≤35% and NYHA Class II-III symptoms with expected survival >1 year 2

Cardiac Resynchronization Therapy (CRT)

• Recommended for patients with LVEF ≤35%, QRS duration ≥150ms with LBBB morphology 2
• Consider for patients requiring ventricular pacing for high-degree AV block 2

Non-Pharmacological Interventions

Exercise and Rehabilitation

• Class I, Level A recommendation for exercise training to improve functional status 1
• Cardiac rehabilitation is beneficial for improving functional capacity and quality of life (Class IIa, Level B) 1

Sodium and Fluid Restriction

• Sodium restriction is reasonable for symptomatic patients (Class IIa, Level C) 1
• Limit fluid intake to 1-1.5 L/day in severe heart failure with hyponatremia 2

Self-Care Education

• Class I, Level B recommendation for specific education to facilitate self-care 1
• Daily weight monitoring with instructions to increase diuretic dose if weight increases by 1.5-2.0 kg over 2 days 2

Management of Special Situations

Hyponatremia

• Limit fluid intake to 1-1.5 L/day in severe heart failure with hyponatremia 2
• Avoid rapid correction of hyponatremia 2
• Recognize when hyponatremia is hypovolemic vs. hypervolemic for appropriate treatment 2

Atrial Fibrillation

• Class I, Level A recommendation for anticoagulation in CHF with atrial fibrillation 1

Medications to Avoid

• Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) may be harmful in patients with low LVEF (Class III: Harm, Level C) 1
• Oral positive inotropic agents increase mortality and are not recommended (Class III, Level A) 1
• NSAIDs should be avoided as they can worsen renal function and fluid retention 2
• Alpha-adrenergic blocking drugs are not recommended (Class III, Level B) 1

End-Stage Disease Management

• Consider mechanical circulatory support, continuous intravenous positive inotropic therapy, or referral for cardiac transplantation 2
• Provide palliative care including symptom relief with opiates for patients with end-stage disease 2

Monitoring

• Regular assessment of symptoms, vital signs, weight, and volume status
• Monitor electrolytes and renal function, particularly with combination therapy
• Check electrolytes and renal function 1-2 weeks after each dose increment of ACE inhibitors or ARBs, and every 6 months thereafter 2

Despite the proven efficacy of ACE inhibitors in reducing morbidity and mortality, studies have shown they are underutilized, with only 33-67% of hospitalized patients and 10-36% of community-dwelling patients receiving them 4. Additionally, dosages used in clinical practice are often substantially lower than those proven efficacious in trials 4.