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 mortality and morbidity. 1

Diagnosis and Classification

Heart failure is classified into progressive stages that guide treatment:

• 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)

Initial Pharmacological Management

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 every 2 weeks as tolerated 1
   • Monitor renal function and electrolytes at 1-2 weeks after initiation, after each dose increase, at 3 months, and then every 6 months 1
   • Reduce or withhold diuretics 24 hours before starting ACE inhibitors to prevent hypotension 1

2. Beta-Blockers

   • Recommended for all stable patients with HFrEF in NYHA class II-IV 1
   • Use "start-low, go-slow" approach to avoid bradycardia and hypotension 1
   • Preferred agents: bisoprolol, metoprolol succinate, carvedilol, or nebivolol 1
   • Can be started concurrently with ACE inhibitors; evidence shows similar outcomes regardless of which is started first 1

3. Diuretics

   • Add for patients with fluid retention 1
   • Loop diuretics (e.g., furosemide) or thiazides are recommended as initial therapy 1
   • For insufficient response, increase dose or combine loop diuretics with thiazides 1
   • Monitor electrolytes and renal function regularly 1

Second-Line Therapy

1. Aldosterone Receptor Antagonists (MRAs)

   • Add for patients with advanced heart failure (NYHA III-IV) 1
   • Monitor potassium and renal function 5-7 days after initiation 1

2. Angiotensin Receptor Blockers (ARBs)

   • Alternative for patients who cannot tolerate ACE inhibitors 1
   • May be combined with ACE inhibitors in selected patients, but increases risk of hyperkalemia 1

3. Angiotensin Receptor-Neprilysin Inhibitors (ARNIs)

   • More effective than ACE inhibitors alone in reducing mortality and hospitalization 3
   • Consider replacing ACE inhibitor/ARB with ARNI in appropriate patients 4

4. SGLT2 Inhibitors

   • Recent evidence supports their use as part of quadruple therapy with ARNI, beta-blocker, and MRA 2

Non-Pharmacological Management

1. Exercise and Lifestyle Modifications

   • Regular aerobic exercise is recommended to improve functional capacity and reduce hospitalization risk 1
   • Control sodium intake for patients with severe heart failure 1
   • Avoid excessive fluid intake in severe heart failure 1
   • Avoid excessive alcohol consumption 1

2. Patient Education

   • Explain heart failure pathophysiology and symptom recognition 1
   • Teach self-monitoring (daily weighing) 1
   • Emphasize medication adherence 1
   • Smoking cessation 1

3. Multidisciplinary Care

   • Enrollment in a multidisciplinary care management program reduces hospitalization and mortality 1

Common Pitfalls to Avoid

1. Medication-Related

   • Avoid NSAIDs and COX-2 inhibitors as they increase risk of heart failure worsening 1, 2
   • Avoid abrupt withdrawal of heart failure medications 2
   • Avoid excessive diuresis before starting ACE inhibitors 1
   • Avoid potassium-sparing diuretics during ACE inhibitor initiation 1

2. Management-Related

   • Underutilization of beta-blockers in elderly patients and those with comorbidities 1
   • Failure to titrate medications to target doses proven effective in clinical trials 2
   • Inadequate monitoring of renal function and electrolytes 1

Special Considerations

For patients with heart failure and preserved ejection fraction (HFpEF), treatment options are more limited, as there is still no firmly evidence-based treatment for this condition 5. Management focuses on controlling symptoms and addressing underlying conditions.

For patients with refractory heart failure (Stage D), advanced therapies including cardiac resynchronization therapy, ventricular assist devices, or heart transplantation may be considered 5, 6.