What is the initial management for patients with heart failure?

Initial Management of Heart Failure

The initial management of heart failure should include ACE inhibitors and beta-blockers as first-line therapy for all patients with heart failure with reduced ejection fraction (HFrEF), along with diuretics for those with fluid retention, to reduce morbidity and mortality. 1

Classification and Assessment

Heart failure is classified into four progressive stages:

• Stage A: Patients at risk but without structural heart disease or symptoms
• Stage B: Structural heart disease without symptoms (NYHA class I)
• Stage C: Structural heart disease with current or previous symptoms (NYHA classes I-IV)
• Stage D: Refractory heart failure requiring specialized interventions (NYHA class IV)

Pharmacological Management Algorithm

First-Line Therapy for HFrEF

1. ACE Inhibitors:

   • Start with low doses (e.g., enalapril 2.5 mg daily, lisinopril 2.5-5 mg daily) 2
   • Titrate upward at 2-week intervals to target doses proven effective in clinical trials 2
   • Monitor renal function and electrolytes after 5-7 days of initiation, then at 3 months and every 6 months thereafter 1
   • Consider reducing or withholding diuretics 24 hours before starting ACE inhibitors to prevent hypotension 1

2. Beta-Blockers:

   • Recommended for all patients with HFrEF regardless of symptom severity 1
   • Use a "start-low, go-slow" approach with careful monitoring of heart rate, blood pressure, and clinical status 1
   • Use only evidence-based beta-blockers: bisoprolol, metoprolol succinate, carvedilol, or nebivolol 1
   • Can be initiated concurrently with ACE inhibitors as evidence shows no difference in outcomes whether ACE inhibitor or beta-blocker therapy is started first 1

3. Diuretics:

   • Indicated for all patients with fluid retention 1
   • Initial diuretic treatment: Loop diuretics (e.g., furosemide) or thiazides 1
   • For GFR < 30 ml/min, avoid thiazides except when prescribed synergistically with loop diuretics 1
   • Regularly monitor symptoms, urine output, renal function, and electrolytes 1

Second-Line Therapy

For patients who remain symptomatic despite first-line therapy, add one of the following:

1. Aldosterone Receptor Antagonists (e.g., spironolactone):

   • Recommended for advanced heart failure (NYHA III-IV) 1
   • Monitor potassium and renal function closely 1

2. Angiotensin Receptor Blockers (ARBs):

   • Alternative for patients who cannot tolerate ACE inhibitors 1
   • May be added to ACE inhibitors to improve symptoms and reduce hospitalizations, but increases risk of hyperkalemia 1

3. Combination of Hydralazine and Nitrates:

   • Consider especially in certain ethnic groups 1

Advanced Therapies

For patients with persistent symptoms despite optimal medical therapy:

1. Cardiac Resynchronization Therapy (CRT):

   • For symptomatic patients with QRS duration ≥130 msec and LBBB morphology 1

2. Implantable Cardioverter Defibrillators (ICDs):

   • Consider for prevention of sudden cardiac death 3

3. Angiotensin Receptor-Neprilysin Inhibitor (ARNI):

   • Has shown superior efficacy compared to ACE inhibitors alone in reducing mortality and hospitalizations 4
   • Consider replacing ACE inhibitor or ARB with ARNI in appropriate patients 5

4. SGLT2 Inhibitors:

   • Recent evidence supports their use in HFrEF 6

Non-Pharmacological Management

1. Regular aerobic exercise:

   • Recommended to improve functional capacity and symptoms 1
   • Reduces risk of heart failure hospitalization 1

2. Dietary and social habits:

   • Control sodium intake when necessary, especially in severe heart failure 1
   • Avoid excessive fluid intake in severe heart failure 1
   • Avoid excessive alcohol consumption 1

3. Multidisciplinary care management:

   • Enroll patients in a multidisciplinary care program to reduce hospitalizations and mortality 1

Common Pitfalls and Considerations

• Avoid NSAIDs and COX-2 inhibitors as they increase the risk of heart failure worsening and hospitalization 1, 2
• Avoid thiazolidinediones (glitazones) as they increase the risk of heart failure worsening 1
• Avoid excessive diuresis before starting ACE inhibitors to prevent severe hypotension 1, 2
• Monitor for hyperkalemia when using ACE inhibitors, ARBs, or aldosterone antagonists, especially in combination 1
• Do not abruptly withdraw ACE inhibitors as this can lead to clinical deterioration 2
• Small increases in creatinine (up to 50% from baseline or up to 3 mg/dL) are expected and acceptable with ACE inhibitors 2

By following this structured approach to the initial management of heart failure, clinicians can effectively reduce morbidity and mortality while improving patients' quality of life.