What is the initial management for patients with heart failure?

Initial Management of Heart Failure

The initial management of heart failure should include four foundational medication classes: SGLT2 inhibitors, beta-blockers, renin-angiotensin system inhibitors (ACEi/ARB/ARNi), and mineralocorticoid receptor antagonists (MRAs), as these medications have been shown to significantly reduce mortality and hospitalizations in patients with heart failure with reduced ejection fraction (HFrEF). 1

Assessment and Classification

Before initiating treatment, it's important to:

• Determine the type of heart failure (reduced, mid-range, or preserved ejection fraction)
• Classify severity using the New York Heart Association (NYHA) functional classification
• Identify potential underlying causes and comorbidities

Heart failure is classified into progressive stages:

• Stage A: 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 prior symptoms (NYHA class I-IV)
• Stage D: Refractory heart failure requiring specialized interventions (NYHA class IV) 2

Pharmacological Management

First-Line Therapy for HFrEF

1. SGLT2 Inhibitors

   • Dapagliflozin 10 mg once daily or empagliflozin 10 mg once daily
   • Can be initiated early regardless of diabetes status 1

2. Beta-Blockers

   • Evidence-based options: bisoprolol, metoprolol succinate, or carvedilol
   • Start low and titrate slowly ("start-low, go-slow")
   • Initial doses:
     • Bisoprolol: 1.25 mg once daily
     • Carvedilol: 3.125 mg twice daily
     • Metoprolol succinate: 12.5-25 mg once daily 2, 1

3. Renin-Angiotensin System Inhibitors

   • ARNi (sacubitril/valsartan): First choice for NYHA class II-III
     • Start at 49/51 mg twice daily
     • Target dose: 97/103 mg twice daily 1
   • ACE inhibitors (if ARNi not available/tolerated):
     • Lisinopril: 2.5-5 mg once daily
     • Enalapril: 2.5 mg twice daily
     • Ramipril: 1.25-2.5 mg once daily 1
   • ARBs (if ACEi causes cough/angioedema):
     • Candesartan: 4-8 mg once daily 1

4. Mineralocorticoid Receptor Antagonists (MRAs)

   • Spironolactone: 12.5-25 mg once daily
   • Eplerenone: 25 mg once daily 1

Medication Initiation Strategy

Medications may be started simultaneously at low doses or sequentially:

• For patients with normal blood pressure: Start with SGLT2i and beta-blocker, then add ARNi/ACEi/ARB, followed by MRA
• For patients with low blood pressure: Start with SGLT2i and MRA, then add selective beta-blocker, followed by very low dose ARNi or ACEi/ARB 1

Diuretic Therapy

• Diuretics should be used for patients with fluid retention and congestion
• For new-onset acute heart failure: Initial dose of 20-40 mg IV furosemide (or equivalent)
• For chronic diuretic therapy: Initial IV dose should be at least equivalent to oral dose
• Adjust dose based on symptoms, clinical status, and urine output 2

Monitoring

• Monitor electrolytes and renal function 1-2 weeks after initiation and dose changes
• Regular monitoring of blood pressure and heart rate
• Adjust diuretics according to volume status 1

Device Therapy Considerations

For eligible patients with persistent symptoms despite optimal medical therapy:

• ICD for patients with LVEF ≤35% and NYHA Class II-III symptoms
• CRT for patients with LVEF ≤35%, QRS ≥150ms, and left bundle branch block morphology 1

Lifestyle Modifications

• Limit sodium intake to reduce fluid retention
• Implement structured aerobic exercise program to improve functional capacity
• Smoking cessation and limited alcohol consumption
• Patient education on self-monitoring, salt restriction, and fluid management 1

Common Pitfalls and Caveats

1. Underutilization of beta-blockers in certain subgroups (older adults, peripheral vascular disease, erectile dysfunction, diabetes, pulmonary disease) despite evidence supporting their use 2

2. Premature switching from ACEi to ARB due to minor side effects. This should only be done if ACEi side effects are truly intolerable, as ACEi have stronger evidence base 2

3. Inadequate dose titration - Medications should be titrated to target doses as tolerated, not left at initial doses 1

4. Insufficient monitoring of renal function and electrolytes, particularly when using combinations of ACEi/ARB/ARNi with MRAs 2, 1

5. Failure to enroll patients in multidisciplinary care management programs, which have been shown to reduce hospitalization and mortality 2

By following this comprehensive approach to heart failure management, clinicians can significantly improve symptoms, reduce hospitalizations, and increase survival in patients with heart failure.