What is the initial pharmacological treatment for a patient with heart failure?

Initial Pharmacological Treatment for Heart Failure

The initial medication regimen for patients with heart failure with reduced ejection fraction (HFrEF) should include four foundational drug classes: ACE inhibitors (or ARNIs), beta blockers, mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors to reduce mortality and hospitalization. 1

Core Medication Classes for Heart Failure

First-Line Medications

1. ACE Inhibitors/ARBs/ARNIs

   • Start at low dose and gradually increase to target doses
   • Monitor renal function and electrolyte balance
   • ARBs can be used as alternatives for patients who cannot tolerate ACE inhibitors
   • Consider switching to sacubitril/valsartan (ARNI) in patients who remain symptomatic despite optimal ACE inhibitor therapy 1, 2

2. Beta Blockers

   • Start at very low dose and titrate every 1-2 weeks to maintenance doses
   • Indicated for all stable patients with current or prior symptoms of HF and reduced LVEF 1

3. Mineralocorticoid Receptor Antagonists (MRAs)

   • Recommended for patients with NYHA class III-IV symptoms and LVEF ≤35%
   • Start at 25 mg per day
   • Monitor potassium concentration and renal function 1

4. SGLT2 Inhibitors

   • Add dapagliflozin or empagliflozin to reduce mortality and hospitalization
   • Regularly monitor electrolytes and renal function 1

Diuretic Therapy

• Essential for symptomatic treatment of fluid overload
• Loop diuretics (furosemide, bumetanide, or torsemide) recommended for most heart failure patients
• Adjust dose according to volume status 1

Medication Initiation Strategy

While traditionally ACE inhibitors were initiated first followed by beta-blockers, recent evidence suggests both approaches may be effective:

• The American College of Cardiology recommends including all four foundational drug classes (ACE inhibitors/ARNIs, beta blockers, MRAs, and SGLT2 inhibitors) 1
• The European Society of Cardiology recommends a combination of ACE inhibitors, beta blockers, diuretics, and MRAs as first-line therapy 1

Dosing Considerations

• ACE inhibitors/ARBs: Start at low dose, gradually increase while monitoring renal function
• Beta blockers: Begin at very low dose, titrate slowly every 1-2 weeks
• MRAs: Start at 25 mg daily with careful monitoring
• SGLT2 inhibitors: Add to existing therapy with regular monitoring
• ARNIs: When switching from ACE inhibitor, start at 25-50mg twice daily for patients with low blood pressure 1, 2

Special Considerations

• Fluid Overload: Administer intravenous loop diuretics at doses equal to or exceeding the patient's chronic oral daily dose 1
• Hypotension/Hypoperfusion: Consider intravenous inotropic or vasopressor drugs (e.g., dobutamine) to maintain systemic perfusion 1
• Monitoring Requirements: Daily monitoring should include fluid intake/output, vital signs, body weight, clinical signs of perfusion and congestion, and laboratory values 1

Potential Pitfalls to Avoid

• Underdosing: Many patients receive less than half of the standard dose in real-world practice 3
• Medication Discontinuation: Continue evidence-based oral therapies in most patients, discontinuing only in cases of hemodynamic instability or specific contraindications 1
• Inadequate Follow-up: Careful monitoring of renal function and electrolytes is essential, especially when using combination therapy 1
• Delayed Optimization: Initiate guideline-directed medical therapy prior to discharge once patients are stabilized 1

The comprehensive approach to heart failure management should also include lifestyle modifications, patient education on self-monitoring, and consideration of device therapy when appropriate, but the pharmacological foundation remains these four medication classes.