What is the initial medical management for heart failure?

Initial Medical Management of Heart Failure

The initial medical management of heart failure should include diuretics for fluid overload (20-40 mg IV furosemide), ACE inhibitors for all patients with heart failure due to left ventricular systolic dysfunction, and beta-blockers once the patient is stable on ACE inhibitor therapy, with SGLT2 inhibitors added as part of quadruple therapy to reduce mortality and hospitalizations. 1

Initial Approach to Heart Failure Management

Diuretic Therapy

• Start with 20-40 mg IV furosemide (or equivalent) for new-onset acute heart failure with fluid overload 1
• For patients on chronic diuretic therapy, use at least an equivalent dose 1
• Monitor:
  • Symptoms
  • Urine output
  • Renal function
  • Electrolytes
• Instruct patients to monitor daily weight and report increases of 1.5-2.0 kg over 2 days 1

Foundation Therapy for HFrEF

1. ACE Inhibitors:

   • Start in all patients with heart failure due to left ventricular systolic dysfunction
   • Uptitrate to target doses proven effective in clinical trials
   • For patients without fluid retention, start with ACE inhibitor alone 1
   • For patients with fluid retention, start ACE inhibitor and diuretic concurrently 1

2. Beta-Blockers:

   • Add once patient is stable on ACE inhibitor therapy
   • Start with very low dose and titrate gradually (every 1-2 weeks)
   • Monitor for worsening heart failure, hypotension, or bradycardia 1

3. SGLT2 Inhibitors:

   • Add dapagliflozin or empagliflozin to reduce hospitalization and cardiovascular death 1
   • Particularly beneficial for patients with comorbid diabetes

4. Mineralocorticoid Receptor Antagonists (MRAs):

   • Add spironolactone or eplerenone for patients with persistent symptoms despite other therapies 1

Evidence-Based Quadruple Therapy Approach

The European Society of Cardiology, American College of Cardiology, and American Heart Association recommend a quadruple therapy approach for heart failure with reduced ejection fraction (HFrEF) 1:

1. ACE inhibitors (or ARBs)
2. Beta-blockers
3. Mineralocorticoid receptor antagonists
4. SGLT2 inhibitors

This combination has shown the strongest evidence for reducing mortality and hospitalizations in patients with HFrEF.

Common Pitfalls and Caveats

• Underutilization of guideline-directed therapy: Only 1% of eligible patients receive target doses of all recommended medications 1
• Excessive concern about low blood pressure: This should not prevent initiation or uptitration of therapy 1
• Suboptimal dosing: Most patients receive doses lower than those proven efficacious in clinical trials 2
• Delayed initiation of beta-blockers: These should be added once the patient is stable on ACE inhibitor therapy, not withheld indefinitely 1
• Inappropriate use of inotropes: These should be avoided unless the patient is symptomatically hypotensive or hypoperfused due to safety concerns 1

Special Considerations

Ivabradine

• Consider for patients with heart failure who have a resting heart rate ≥70 bpm despite maximally tolerated beta-blocker therapy 3
• SHIFT trial demonstrated reduction in hospitalization for worsening heart failure but no significant effect on cardiovascular mortality 3

Advanced Therapies

• For end-stage disease, consider:
  • Mechanical circulatory support
  • Continuous intravenous positive inotropic therapy
  • Referral for cardiac transplantation 1

Patient Education and Follow-up

• Provide education on self-monitoring, salt restriction, and fluid management
• Limit sodium intake to reduce fluid retention and symptoms
• Implement structured aerobic exercise program starting with low-intensity exercise
• Recommend smoking cessation and limited alcohol consumption 1

Heart failure management requires a systematic approach with careful attention to medication selection, dosing, and monitoring to achieve optimal outcomes and reduce mortality and hospitalizations.