What is the first-line treatment for Congestive Heart Failure (CHF)?

First-Line Treatment for Congestive Heart Failure (CHF)

The first-line treatment for congestive heart failure with reduced ejection fraction (HFrEF) should be a combination of an ACE inhibitor and a beta-blocker, which significantly reduce mortality and morbidity in patients with left ventricular systolic dysfunction. 1, 2

Treatment Algorithm Based on Heart Failure Type

For Heart Failure with Reduced Ejection Fraction (HFrEF):

1. Initial Dual Therapy (Start both simultaneously):

   • ACE inhibitor (e.g., lisinopril, enalapril, ramipril)
   • Beta-blocker (specifically carvedilol, metoprolol succinate, or bisoprolol)

2. Add-on Therapy (if symptoms persist):

   • Mineralocorticoid receptor antagonist (MRA) like spironolactone 3
   • SGLT2 inhibitor (dapagliflozin or empagliflozin) 2

3. Further Options (if needed):

   • Consider switching ACE inhibitor to angiotensin receptor-neprilysin inhibitor (ARNI)
   • ARBs if ACE inhibitors are not tolerated (cough, angioedema)
   • Diuretics for symptom relief (fluid overload)

For Heart Failure with Preserved Ejection Fraction (HFpEF):

• Diuretics for volume control 1
• ACE inhibitors or ARBs and beta-blockers for persistent hypertension 1

Medication Specifics

ACE Inhibitors

• Proven to reduce mortality and hospitalizations 1, 4
• Start at low dose and titrate up (e.g., lisinopril 2.5-5 mg daily, target 20-40 mg daily) 2, 4
• Monitor renal function and potassium levels

Beta-Blockers

• Reduce mortality even in older adults 1
• Only use evidence-based beta-blockers: carvedilol, metoprolol succinate, or bisoprolol 1, 2, 5
• "Start low, go slow" approach to avoid hypotension and bradycardia 1
• Target doses: bisoprolol 10 mg daily, carvedilol 25-50 mg twice daily, metoprolol succinate 200 mg daily 2

Mineralocorticoid Receptor Antagonists (MRAs)

• Add for patients with LVEF ≤35% and NYHA class II-IV symptoms 2
• Spironolactone 12.5-25 mg daily or eplerenone 25 mg daily 2, 3
• Careful monitoring of renal function and potassium required

SGLT2 Inhibitors

• Newer addition to heart failure therapy 2
• Reduce heart failure hospitalizations and cardiovascular mortality
• Examples: dapagliflozin 10 mg daily, empagliflozin 10 mg daily

Important Clinical Considerations

• Initiation Sequence: Evidence shows similar outcomes whether ACE inhibitor or beta-blocker is started first 1, so both can be initiated simultaneously if hemodynamically stable
• Medication Titration: Gradually increase doses to target levels as tolerated
• Monitoring: Regular assessment of renal function, electrolytes, blood pressure, and heart rate
• Common Pitfalls to Avoid:
  • Underutilization of beta-blockers in older adults or those with comorbidities 1
  • Premature switching from ACE inhibitors to ARBs without trying to manage side effects 1
  • Using non-evidence-based beta-blockers instead of the proven ones (carvedilol, metoprolol succinate, bisoprolol) 1, 2
  • Nondihydropyridine calcium channel blockers (verapamil, diltiazem) should be avoided in HFrEF as they can worsen outcomes 1

The evidence strongly supports initiating both ACE inhibitors and beta-blockers as cornerstone therapy for CHF with reduced ejection fraction, with subsequent addition of MRAs and SGLT2 inhibitors to form comprehensive quadruple therapy for optimal reduction in mortality and hospitalizations 2.