What are the current treatment recommendations for congestive heart failure (CHF) with decreased ejection fraction?

Current Treatment Recommendations for Heart Failure with Reduced Ejection Fraction

Quadruple therapy with SGLT2 inhibitors, beta-blockers, renin-angiotensin system inhibitors (preferably ARNI), and mineralocorticoid receptor antagonists is strongly recommended as the cornerstone of treatment for heart failure with reduced ejection fraction (HFrEF) to significantly reduce mortality and hospitalizations. 1

First-Line Pharmacological Therapy

Core Medications for HFrEF

1. SGLT2 Inhibitors

   • Dapagliflozin 10 mg once daily or Empagliflozin 10 mg once daily 1
   • Reduces risk of HF hospitalization and cardiovascular death 2, 1

2. Beta-Blockers

   • Evidence-based options:
     • Metoprolol succinate (starting 12.5-25 mg daily, target 200 mg daily)
     • Carvedilol (starting 3.125 mg twice daily, target 25-50 mg twice daily)
     • Bisoprolol (starting 1.25 mg daily, target 10 mg daily) 1
   • Start at low dose and titrate every 2 weeks if tolerated 1

3. Renin-Angiotensin System Inhibitors

   • First choice: Sacubitril/Valsartan (ARNI)

     • Starting dose: 49/51 mg twice daily
     • Target dose: 97/103 mg twice daily 1
     • Indicated to reduce risk of cardiovascular death and HF hospitalization 3
     • Recommended as replacement for ACE-I/ARB in HFrEF 2

   • Alternative if ARNI not tolerated/available:

     • ACE inhibitors (e.g., Lisinopril, Enalapril, Ramipril) 1
     • ARBs for patients unable to tolerate ACE-I or ARNI 2

4. Mineralocorticoid Receptor Antagonists (MRAs)

   • Spironolactone (starting 12.5-25 mg daily, target 25-50 mg daily) 1, 4
   • Eplerenone (starting 25 mg daily, target 50 mg daily) 1
   • Indicated for NYHA Class III-IV HF with reduced EF 4
   • Monitor potassium and renal function closely 1

Device Therapy

1. Implantable Cardioverter-Defibrillator (ICD)

   • Recommended for:
     • Primary prevention in patients with NYHA class II-III symptoms on optimal medical therapy with EF ≤35% 1
     • Patients who have recovered from ventricular arrhythmia causing hemodynamic instability 2
   • Expected survival >1 year with good functional status 2

2. Cardiac Resynchronization Therapy (CRT)

   • Recommended for patients with:
     • LVEF ≤35%
     • QRS duration ≥150 ms
     • Left bundle branch block morphology 2, 1
   • Improves symptoms, survival, and reduces morbidity 2
   • Preferred over right ventricular pacing for patients with HFrEF regardless of NYHA class or QRS width who need ventricular pacing 2

Lifestyle Modifications

1. Sodium and Fluid Management

   • Moderate sodium restriction to reduce fluid retention 1
   • Fluid restriction of 1.5-2 L/day in advanced heart failure 1
   • Daily weight monitoring with action plan for weight gain >2 kg in 3 days 1

2. Physical Activity

   • Regular, structured aerobic exercise program starting with low intensity 1
   • Enrollment in a multidisciplinary HF management program 2

3. Other Recommendations

   • Smoking cessation 1
   • Limit alcohol consumption to moderate intake 1

Medication Titration Strategy

Recent guidelines emphasize starting all four key life-saving therapies as quickly as possible, with dose titration as a secondary consideration 5. Even low doses of these medications provide early benefits, and the "target dose" in clinical trials was often not reached in many patients 5.

Advanced Treatment Options

For patients with end-stage disease:

• Consider mechanical circulatory support
• Evaluate for heart transplantation
• Consider continuous intravenous inotropic support as bridge therapy 1
• Transcatheter mitral valve repair for selected patients with functional mitral regurgitation 1

Medications to Avoid in HFrEF

• NSAIDs and COX-2 inhibitors
• Non-dihydropyridine calcium channel blockers (verapamil, diltiazem)
• Class I anti-arrhythmic agents
• Tricyclic antidepressants
• Short-acting dihydropyridine calcium antagonists 1

Monitoring

• Regular assessment of renal function and electrolytes, especially with diuretics, ACE inhibitors, or ARBs 1
• Serial monitoring of natriuretic peptide levels to guide therapy 1
• Regular follow-up to assess symptom control and medication tolerance

The combination of ARNi, beta-blocker, MRA, and SGLT2i has been shown to be most effective in reducing all-cause death (HR: 0.39; 95% CI: 0.31-0.49) and may provide an estimated additional 5 years of life for a 70-year-old patient compared with no treatment 6.