Medications for Heart Failure Treatment
The cornerstone medications for heart failure treatment include ACE inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors, which should be initiated in a stepwise approach to reduce mortality and hospitalizations. 1
First-Line Medications
ACE Inhibitors
- First-line therapy for patients with reduced left ventricular ejection fraction (LVEF)
- Start at low dose and gradually titrate up to target dose
- Monitor renal function and electrolytes during titration
- Examples include enalapril, lisinopril, ramipril
Beta-Blockers
- Indicated for all stable patients with current or prior symptoms of heart failure and reduced LVEF
- Only three beta-blockers have proven mortality benefits:
- Titration guidelines:
- Double dose at not less than 2-week intervals
- Monitor heart rate, blood pressure, and clinical status
- Check blood chemistry 12 weeks after initiation and after final dose titration 2
Loop Diuretics
- Essential for symptomatic treatment of fluid overload
- Initial doses:
- Furosemide: 20-40mg
- Bumetanide: 0.5-1.0mg
- Torsemide: 10-20mg 1
- Adjust dose based on symptoms and fluid status
Second-Line Medications
Mineralocorticoid Receptor Antagonists (MRAs)
- Recommended for patients with NYHA class III-IV symptoms and LVEF ≤35%
- Spironolactone is indicated for NYHA Class III-IV heart failure with reduced ejection fraction to:
- Increase survival
- Manage edema
- Reduce hospitalization 3
- Usually administered with other heart failure therapies
- Monitor potassium levels and renal function
Angiotensin Receptor Blockers (ARBs)
- Alternative for patients who cannot tolerate ACE inhibitors
- Similar efficacy to ACE inhibitors in heart failure 1
SGLT2 Inhibitors
- Dapagliflozin or empagliflozin should be added to reduce mortality and hospitalization
- Regular monitoring of electrolytes and renal function required 1
Special Considerations
Heart Rate Control
- For patients with elevated heart rate despite beta-blocker therapy, ivabradine may be considered
- Monitor for side effects including:
- Atrial fibrillation
- Bradycardia
- Visual disturbances (phosphenes) 4
Medication Titration Challenges
- If worsening symptoms occur during beta-blocker initiation:
- For increasing congestion: double diuretic dose and/or halve beta-blocker dose
- For fatigue/bradycardia: halve beta-blocker dose
- For serious deterioration: consider stopping beta-blocker (rarely necessary) and seek specialist advice 2
- Never stop beta-blockers suddenly unless absolutely necessary due to risk of rebound ischemia/arrhythmias 2
Monitoring and Follow-up
- Monitor serum electrolytes, urea nitrogen, and creatinine during treatment
- Assess daily weight, urine output, and volume status
- Patients should weigh themselves daily and increase diuretic dose if weight increases by 1.5-2.0kg over 2 days 2, 1
- Regular follow-up at 1-2 weeks after each dose increment and every 6 months thereafter
Optimization of Therapy
- Despite clear benefits, GDMT (Guideline-Directed Medical Therapy) remains underutilized in clinical practice 5, 6
- Heart failure clinic referral is associated with higher rates of appropriate medication initiation 5
- The greatest benefit occurs when medications from all four main drug classes are used together 6
Common Pitfalls to Avoid
- Inadequate dose titration of beta-blockers and ACE inhibitors
- Premature discontinuation of beta-blockers due to temporary symptom worsening
- Failure to monitor electrolytes and renal function
- Not educating patients about self-monitoring weight changes
- Abrupt discontinuation of beta-blockers
- Not considering specialist referral for complex cases
Remember that some heart failure is better than no beta-blocker in heart failure management, and temporary symptomatic deterioration during initiation (occurring in 20-30% of cases) can usually be managed with medication adjustments rather than discontinuation 2.