Medications for Managing Congestive Heart Failure
The cornerstone medications for managing congestive heart failure include ACE inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRAs), diuretics, and SGLT2 inhibitors, with specific agents and doses tailored to the severity of heart failure and ejection fraction status.
First-Line Medications
ACE Inhibitors
- First-line treatment for patients with reduced ejection fraction 1
- Start with low doses and titrate up to target doses 1
- Examples and dosing:
- Captopril: Start 6.25mg TID, target 50-100mg TID
- Enalapril: Start 2.5mg BID, target 10-20mg BID
- Lisinopril: Start 2.5-5.0mg daily, target 30-35mg daily
- Ramipril: Start 2.5mg daily, target 5mg BID or 10mg daily
- Trandolapril: Start 1.0mg daily, target 4mg daily 1
Beta-Blockers
- Indicated for all patients with reduced ejection fraction (Class I, Level A) 1, 2
- Should be started at low dose and gradually titrated every 1-2 weeks 2
- Patients should be on background ACE inhibitor therapy if not contraindicated 1
- Common agents:
- Carvedilol
- Metoprolol succinate
- Bisoprolol
Mineralocorticoid Receptor Antagonists (MRAs)
- Recommended for patients with NYHA class III-IV symptoms and LVEF ≤35% 2
- Options include:
- Spironolactone
- Eplerenone
Diuretics
- Used for symptom management in fluid overload 1
- Loop diuretics (e.g., furosemide) are first-line for congestion
- Can be administered intravenously for acute decompensation 2
- Initial bolus of furosemide 20-40mg IV (or equivalent) 2
SGLT2 Inhibitors
- Newer agents with proven mortality and hospitalization benefits 1, 2
- Options:
- Dapagliflozin
- Empagliflozin
- Particularly beneficial in HFpEF (heart failure with preserved ejection fraction) 1
Second-Line and Alternative Medications
Angiotensin Receptor Blockers (ARBs)
- Alternative for patients who cannot tolerate ACE inhibitors 2, 3
- Examples include:
- Valsartan
- Candesartan
- Losartan
Angiotensin Receptor-Neprilysin Inhibitors (ARNIs)
- Sacubitril/valsartan combination
- Beneficial in both HFrEF and HFpEF 1
Cardiac Glycosides
- Digoxin indicated for:
- Atrial fibrillation with heart failure (to control ventricular rate)
- Persistent symptoms despite ACE inhibitor and diuretic treatment 1
- Usual daily dose: 0.25-0.375mg (0.125-0.25mg in elderly) 1
Ivabradine
- For patients with heart failure, LVEF ≤35%, and resting heart rate ≥70 bpm 4
- Particularly useful when beta-blockers cannot be used at target doses
- Reduces hospitalization for worsening heart failure 4
Special Considerations
Medication Titration
- Start with low doses and gradually increase to target doses 1
- Monitor for adverse effects:
Management of Adverse Effects
- For hypotension: Consider reducing vasodilators before beta-blockers 1
- For worsening symptoms: Increase diuretics or ACE inhibitors before reducing beta-blockers 1
- For bradycardia: Reduce medications that lower heart rate; reduce beta-blocker dose if necessary 1
Advanced Heart Failure
- For end-stage disease, consider:
- Mechanical circulatory support
- Continuous intravenous positive inotropic therapy
- Referral for cardiac transplantation 2
- Palliative care including symptom relief with opiates for end-stage disease 2
Medication Benefits on Mortality and Hospitalization
| Medication | Deaths prevented per 1000 patient-years | Hospital admissions prevented per 1000 patient-years |
|---|---|---|
| ACE inhibitors | 13 | 99 |
| Beta-blockers | 38 | 65 |
| Spironolactone | 57 | 138 |
| Digoxin | Not significant | 40 |
Data from 1
High-dose ACE inhibitors have shown greater benefits than low doses, with a 12% lower risk of death or hospitalization and 24% fewer heart failure hospitalizations 5, 6.
Remember that medication management should be accompanied by lifestyle modifications including sodium restriction, fluid management, regular exercise, and daily weight monitoring 2.