What is the optimal management strategy for patients with heart failure?

Optimal Management of Heart Failure

The cornerstone of heart failure management is a stepwise pharmacological approach starting with ACE inhibitors and beta-blockers, followed by mineralocorticoid receptor antagonists and SGLT2 inhibitors, along with structured lifestyle modifications and device therapy when indicated. 1, 2

Classification and Diagnosis

Heart failure is classified based on ejection fraction:

• Heart failure with reduced ejection fraction (HFrEF): EF ≤40%
• Heart failure with preserved ejection fraction (HFpEF): EF ≥50%
• Heart failure with mid-range ejection fraction (HFmrEF): EF 41-49%

Diagnostic evaluation should include:

• Echocardiography to assess ventricular function, size, wall thickness, and valve function 2
• Natriuretic peptides (BNP, NT-proBNP) when clinical uncertainty exists 1
• 12-lead ECG and chest radiography 1

Pharmacological Management for HFrEF

First-Line Therapy

1. ACE inhibitors (e.g., lisinopril)

   • Reduces mortality and hospitalization 2, 1
   • Improves symptoms and quality of life 3
   • Monitor for hypotension, renal dysfunction, and hyperkalemia 3

2. Beta-blockers

   • Add to ACE inhibitors for stable symptomatic patients 2, 1
   • Reduces mortality and hospitalization 2
   • Start at low dose and titrate gradually

Second-Line Therapy

1. Mineralocorticoid receptor antagonists (MRAs)

   • Add when patients remain symptomatic despite ACE inhibitor and beta-blocker therapy 2, 1
   • Monitor potassium and renal function closely 1

2. SGLT2 inhibitors

   • Recommended regardless of ejection fraction 1
   • Reduces hospitalization and cardiovascular death 1, 4

Additional Therapies

1. Diuretics

   • Essential for symptomatic treatment of fluid overload 1
   • Adjust dose based on symptoms and volume status 2

2. Angiotensin receptor-neprilysin inhibitors (ARNIs)

   • Consider for patients who remain symptomatic despite optimal therapy 1

3. Hydralazine and nitrates

   • Particularly beneficial in African American patients 1
   • Alternative for patients who cannot tolerate ACE inhibitors 2

4. Digoxin

   • Consider for patients not adequately responsive to ACE inhibitors and diuretics 1
   • Useful for rate control in atrial fibrillation 1

Management of HFpEF

• SGLT2 inhibitors have shown benefit in HFpEF 1, 4
• Non-steroidal mineralocorticoid receptor antagonists 4
• Glucagon-like peptide-1 receptor agonists, especially in obese and diabetic patients 4
• Control of hypertension and other comorbidities 2

Device Therapy

• Cardiac Resynchronization Therapy (CRT): Consider for patients with LVEF <35% and QRS duration ≥150 ms 1
• Implantable Cardioverter-Defibrillator (ICD): Consider for patients with LVEF <35% for prevention of sudden cardiac death 1

Lifestyle Modifications

Diet

• Sodium restriction: Initially 3 g/day; more severe cases may require 2 g/day or less 5
• Modest alcohol intake: 2 units/day for men, 1 unit/day for women; abstinence recommended for alcohol-induced cardiomyopathy 2
• Maintain healthy weight; weight loss for obese patients 1, 6

Physical Activity

• Regular moderate exercise (walking, cycling) is beneficial 1, 7
• Avoid isometric exercises 1
• Supervised exercise-based rehabilitation programs for stable patients 1

Self-Care

• Daily weight monitoring 1
• Medication adherence 1, 5
• Recognition of worsening symptoms 1
• Smoking cessation 1, 6
• Annual influenza vaccination 2

Multidisciplinary Management

• Regular follow-up with structured assessment of symptoms, volume status, and medication effects 1
• Disease management programs with nurse case management 1
• Palliative care for advanced heart failure to improve quality of life 1

Advanced Heart Failure (Stage D)

For refractory end-stage heart failure:

• Evaluate for mechanical circulatory support 2
• Consider heart transplantation 2
• Palliative care for symptom management 1

Monitoring

• Regular assessment of volume status at each visit 1
• Laboratory monitoring of renal function and electrolytes, especially with ACE inhibitors, ARBs, and MRAs 1
• Serial assessment of functional capacity and quality of life 1

By implementing this comprehensive approach to heart failure management, focusing on evidence-based pharmacotherapy, appropriate device therapy, lifestyle modifications, and multidisciplinary care, clinicians can significantly improve morbidity, mortality, and quality of life for patients with heart failure.