What medications are recommended for treating heart failure?

Medications for Heart Failure

The cornerstone medications for heart failure with reduced ejection fraction (HFrEF) include ACE inhibitors, beta-blockers, mineralocorticoid receptor antagonists, SGLT2 inhibitors, and diuretics, with sacubitril/valsartan recommended to further reduce mortality and hospitalization risk. This evidence-based approach is supported by multiple clinical guidelines.

First-Line Medications

ACE Inhibitors

• Recommended as first-line therapy for all patients with reduced left ventricular ejection fraction (LVEF) 1
• Start at low dose and gradually titrate to target doses proven effective in clinical trials 2
• Monitor renal function and electrolytes 1-2 weeks after each dose increase 2
• Examples: lisinopril, enalapril, captopril

Beta-Blockers

• Recommended for all stable patients with current or prior symptoms of HF and reduced LVEF 2
• Only three beta-blockers have proven mortality benefit: bisoprolol, carvedilol, and sustained-release metoprolol succinate 2
• Should be initiated after patient is stabilized on ACE inhibitor therapy 1
• Start at low dose and titrate gradually every 1-2 weeks 1

Diuretics

• Essential for symptomatic treatment when fluid overload is present 2
• Should always be administered in combination with ACE inhibitors when possible 2
• Loop diuretics (furosemide, bumetanide, torsemide) are preferred for most heart failure patients 2
• Initial doses: furosemide 20-40mg, bumetanide 0.5-1.0mg, torsemide 10-20mg 2

Additional Evidence-Based Therapies

Mineralocorticoid Receptor Antagonists (MRAs)

• Recommended for patients with NYHA class III-IV symptoms and LVEF ≤35% 1
• Examples: spironolactone (12.5-25mg daily), eplerenone
• Monitor for hyperkalemia, especially when combined with ACE inhibitors 2

Angiotensin Receptor Blockers (ARBs)

• Alternative for patients who cannot tolerate ACE inhibitors 2, 1
• Similar efficacy to ACE inhibitors in heart failure 1
• Examples: valsartan, candesartan, losartan

SGLT2 Inhibitors

• Recent addition to heart failure therapy 1
• Dapagliflozin or empagliflozin recommended to reduce mortality and hospitalization 1
• Require regular monitoring of electrolytes and renal function

Sacubitril/Valsartan

• Indicated to reduce risk of cardiovascular death and hospitalization for heart failure in adults 3
• Most beneficial in patients with LVEF below normal 3
• Starting dose: 49/51 mg twice daily, target dose: 97/103 mg twice daily 3
• Requires 36-hour washout period when switching from ACE inhibitor 3

Medication Initiation and Titration

ACE Inhibitors/ARBs

1. Review need for and dose of diuretics and vasodilators
2. Consider reducing diuretics for 24 hours before starting
3. Start with low dose and build up to target doses
4. Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increase 2
5. Avoid potassium-sparing diuretics during initiation
6. Avoid NSAIDs 2

Beta-Blockers

1. Start at low dose after patient is stable on ACE inhibitor
2. Titrate gradually every 1-2 weeks
3. Monitor for bradycardia and worsening heart failure symptoms
4. May temporarily cause myocardial depression during titration 2

Common Pitfalls and Caveats

1. Underdosing of ACE inhibitors: Many clinicians prescribe lower doses than those proven effective in clinical trials. The ATLAS study showed high doses of lisinopril (32.5-35mg) provided greater reduction in hospitalizations compared to low doses (2.5-5mg) 4.

2. Drug interactions: Avoid NSAIDs in heart failure patients as they can worsen renal function and cause fluid retention 2.

3. Inappropriate discontinuation: Don't discontinue beta-blockers during acute decompensation unless absolutely necessary; consider dose reduction instead.

4. Inadequate monitoring: Regular assessment of electrolytes and renal function is essential, particularly with combination therapy of ACE inhibitors, MRAs, and diuretics 1.

5. Delayed initiation of comprehensive therapy: Guidelines support early initiation of multiple evidence-based therapies rather than sequential addition over extended periods.

By following this medication approach and avoiding these common pitfalls, clinicians can optimize outcomes for patients with heart failure, reducing mortality and hospitalizations while improving quality of life.