What is the initial treatment for a patient with heart failure, particularly those with reduced ejection fraction?

Initial Treatment for Heart Failure with Reduced Ejection Fraction

For patients with heart failure with reduced ejection fraction (HFrEF), the initial treatment should include four foundational medication classes: SGLT2 inhibitors, mineralocorticoid receptor antagonists (MRAs), beta-blockers, and renin-angiotensin system inhibitors (ACEi/ARB/ARNi), with diuretics added for symptomatic fluid retention.

Core Medication Classes for HFrEF

First-Line Medications

1. SGLT2 Inhibitors

   • Start early as they have minimal impact on blood pressure 1
   • Dapagliflozin or empagliflozin recommended for all patients with eGFR >20 ml/min/1.73m² 2
   • Monitor electrolytes and renal function regularly

2. Mineralocorticoid Receptor Antagonists (MRAs)

   • Spironolactone indicated for NYHA Class III-IV heart failure 3
   • Minimal impact on blood pressure 1
   • Monitor potassium and renal function (avoid if serum creatinine >2.5 mg/dL in men, >2.0 mg/dL in women, or potassium >5.0 mEq/L) 4

3. Beta-Blockers

   • Only three have proven mortality benefit: bisoprolol, carvedilol, and sustained-release metoprolol succinate 2
   • Start at low dose if heart rate >70 bpm and gradually titrate 1
   • Consider selective β₁ receptor blockers if blood pressure is low 1
   • If beta-blockers are not tolerated, consider ivabradine for patients in sinus rhythm 1

4. Renin-Angiotensin System Inhibitors

   • Options include:
     • Sacubitril/valsartan (ARNi): Start at low dose (50mg BID) or very low dose (25mg BID) if BP is low 1
     • ACE inhibitors: Enalapril has shown 11% reduction in all-cause mortality and 30% reduction in HF hospitalization 5
     • ARBs: Alternative for patients who cannot tolerate ACE inhibitors 2
   • Start at low doses and gradually titrate with monitoring of renal function and electrolytes 1-2 weeks after each dose increase 2

Symptomatic Treatment

• Loop Diuretics: Essential for patients with fluid retention 1, 2
  • Initial doses: furosemide 20-40mg, bumetanide 0.5-1.0mg, torsemide 10-20mg 2
  • Monitor fluid intake/output, vital signs, body weight, and clinical signs of congestion 1
  • If diuresis is inadequate, consider higher doses, adding a second diuretic, or continuous infusion 1

Treatment Algorithm

For Newly Diagnosed HFrEF:

1. Assess volume status:

   • If fluid overload present, start loop diuretic immediately 1, 2
   • Monitor daily weight, electrolytes, and renal function 1

2. Initiate disease-modifying therapy:

   • For patients with normal blood pressure:

     • Start all four medication classes at low doses with sequential up-titration 6

   • For patients with low blood pressure:

     • Start SGLT2i and MRA first (least impact on BP) 1
     • Then add beta-blocker if HR >70 bpm or low-dose ACEi/ARB/ARNi 1
     • Up-titrate one drug at a time in small increments every 1-2 weeks 1

3. Up-titration strategy:

   • Target doses proven effective in clinical trials 2
   • Monitor renal function and electrolytes 1-2 weeks after each dose increase 2
   • Continue medications even during hospitalization unless hemodynamically unstable 1

Special Considerations

Low Blood Pressure Challenges

• If BP is low but patient is asymptomatic, still initiate all four medication classes but at lower doses 1
• Consider spacing medications throughout the day to minimize hypotensive effects 1
• For symptomatic low BP, prioritize medications based on clinical profile:
  • If HR <60 bpm: Reduce beta-blocker first 1
  • If K >5.0 mEq/L: Reduce MRA first 1
  • If eGFR <30 ml/min: Adjust RAS inhibitor doses 1

Common Pitfalls to Avoid

1. Delaying quadruple therapy - All four medication classes should be initiated promptly rather than waiting for clinical deterioration 2, 6
2. Inadequate diuresis - Insufficient diuresis leads to persistent congestion; intensify regimen if needed 1
3. Premature discontinuation during hospitalization - Continue HFrEF medications during hospitalization unless hemodynamically unstable 1
4. Failure to monitor - Regular assessment of electrolytes, renal function, and volume status is essential 1, 2
5. Underutilization of GDMT - Despite proven benefits, these medications are often underutilized or underdosed 6

Monitoring Recommendations

• Monitor serum electrolytes, urea nitrogen, and creatinine during treatment 2
• Assess daily weight, urine output, and volume status 1, 2
• Schedule follow-up 1-2 weeks after each dose increment 2
• Provide comprehensive written discharge instructions covering medications, diet, activity level, follow-up appointments, daily weight monitoring, and warning signs 1

The evidence clearly supports early initiation of all four medication classes for mortality reduction in HFrEF, with careful titration based on patient tolerance and close monitoring of clinical response and laboratory parameters.