What is the initial management for congestive heart failure (CHF) with reduced ejection fraction (HFrEF)?

Initial Management for Heart Failure with Reduced Ejection Fraction (HFrEF)

For patients with newly diagnosed HFrEF, the initial management should include four foundational medication classes: SGLT2 inhibitors, mineralocorticoid receptor antagonists (MRAs), beta-blockers, and renin-angiotensin system inhibitors (preferably ARNI), which should be initiated early and sequentially to reduce mortality and hospitalization. 1

Core Medication Classes for HFrEF

First-Line Medications

1. ACE inhibitors/ARBs/ARNIs

   • ACE inhibitors reduce morbidity and mortality in all stages of HFrEF (Level A evidence) 1
   • ARBs are alternatives for patients intolerant to ACE inhibitors 1
   • Sacubitril/valsartan (ARNI) is preferred over ACE inhibitors/ARBs as it further reduces cardiovascular death and HF hospitalization by 20% 1, 2
   • Starting dose: Sacubitril/valsartan 24/26mg BID; Target: 97/103mg BID 1

2. Beta-blockers

   • Reduce mortality and morbidity even in stable HF patients 1
   • Options include:
     • Carvedilol: Start 3.125mg BID; Target: 25mg BID (<85kg) or 50mg BID (≥85kg)
     • Metoprolol succinate: Start 12.5-25mg daily; Target: 200mg daily
     • Bisoprolol: Start 1.25mg daily; Target: 10mg daily 1

3. Mineralocorticoid Receptor Antagonists (MRAs)

   • Reduce mortality and hospitalization in NYHA class II-IV HF 1
   • Options include:
     • Spironolactone: Start 12.5-25mg daily; Target: 25-50mg daily
     • Eplerenone: Start 25mg daily; Target: 50mg daily 1

4. SGLT2 Inhibitors

   • Improve outcomes regardless of diabetic status 2, 1
   • Options include:
     • Dapagliflozin: 10mg daily
     • Empagliflozin: 10mg daily 1

5. Diuretics

   • Loop diuretics are first-line for volume overload
   • Aim for euvolemia with lowest effective dose
   • Thiazides may be added for resistant edema 1

Implementation Strategy

Initiation Approach

1. Simultaneous vs. Sequential Start

   • Medications may be started simultaneously at low doses or sequentially 2
   • For frail or elderly patients, consider more gradual uptitration 1

2. Titration Schedule

   • Schedule frequent follow-ups (every 1-2 weeks initially) 1
   • Assess vital signs, volume status, renal function, and electrolytes at each visit 1
   • After hospital discharge, follow-up within 7-14 days to adjust medications 1

3. Monitoring Parameters

   • Blood pressure
   • Heart rate
   • Renal function (creatinine, eGFR)
   • Electrolytes (particularly potassium)
   • Symptoms of congestion or hypoperfusion 1

Special Populations and Considerations

African American Patients

• Consider adding hydralazine and isosorbide dinitrate to standard therapy, especially in African American patients who remain symptomatic despite optimal therapy 2

Patients with Comorbidities

• Renal Impairment: Ivabradine has minimal effect with creatinine clearance 15-60 mL/min 3
• Hepatic Impairment: Ivabradine can be used in mild to moderate hepatic impairment 3
• Coronary Artery Disease: In HF patients with LVEF ≤35% and suspected obstructive CAD, invasive coronary angiography is recommended with view toward CABG 2

Device Therapy Considerations

• ICD recommended for:

  • Symptomatic HF (NYHA class II-III) of ischemic etiology with LVEF ≤35% despite ≥3 months of optimized medical treatment 2, 1
  • Patients who have recovered from ventricular arrhythmia causing hemodynamic instability 2

• CRT recommended for:

  • Symptomatic HF with sinus rhythm, LVEF ≤35% despite GDMT, and QRS duration ≥150 ms with LBBB morphology 2, 1
  • Patients with HFrEF requiring ventricular pacing for high-degree AV block 2

Common Pitfalls and Caveats

1. Underutilization of GDMT

   • ACEi/ARB underuse is associated with almost twofold increased risk of all-cause mortality 4
   • Failure to titrate medications to target doses reduces effectiveness 1

2. Barriers to Optimal Therapy

   • Common reasons for suboptimal beta-blocker dosing: hypotension (45%), fatigue (32%), dyspnea (14%), dizziness (12%) 3
   • Perceived contraindications often prevent appropriate medication use 4

3. Medication Sequencing

   • Don't delay initiation of additional medication classes while waiting to reach target doses of current medications 1
   • All four foundational medication classes provide additive benefits 5

4. Follow-up Importance

   • Enrollment in a multidisciplinary HF management program is recommended to reduce hospitalization and improve survival 2
   • Regular monitoring is essential for medication adjustment and outcome improvement 1

The 5-year survival rate after hospitalization for HFrEF remains at only 25%, highlighting the importance of prompt and comprehensive implementation of these evidence-based therapies 6.