What is the initial workup and treatment for a patient with congestive heart failure (CHF)?

Initial Workup and Treatment for Congestive Heart Failure

The initial workup for congestive heart failure (CHF) must include a thorough history and physical examination, laboratory tests (CBC, electrolytes, renal function, thyroid function, lipid profile), 12-lead ECG, chest radiograph, and echocardiography to assess left ventricular ejection fraction, followed by evidence-based pharmacological therapy based on heart failure stage and ejection fraction.

Initial Clinical Assessment

History and Physical Examination

• Identify cardiac and non-cardiac disorders that might cause or accelerate CHF 1
• Document current and past use of alcohol, illicit drugs, alternative therapies, and chemotherapy 1
• Assess patient's ability to perform routine and desired activities of daily living 1
• Evaluate for key symptoms:
  • Dyspnea, orthopnea, paroxysmal nocturnal dyspnea
  • Fatigue and exercise intolerance
  • Peripheral edema
  • Bendopnea (shortness of breath when bending forward) 2

Physical Examination Components

• Volume status assessment (jugular venous distension, peripheral edema)
• Orthostatic blood pressure changes
• Weight and height measurement with BMI calculation 1
• Cardiac examination for:
  • Displaced cardiac apex (cardiomegaly)
  • Third heart sound (S3)
  • Murmurs suggesting valvular disease

Initial Diagnostic Testing

Required Laboratory Tests 1

• Complete blood count
• Urinalysis
• Serum electrolytes (including calcium and magnesium)
• Blood urea nitrogen and serum creatinine
• Fasting blood glucose (glycohemoglobin)
• Lipid profile
• Liver function tests
• Thyroid-stimulating hormone

Imaging and Other Tests

• 12-lead electrocardiogram 1
• Chest radiograph (PA and lateral) 1
• Two-dimensional echocardiography with Doppler to assess:
  • Left ventricular ejection fraction (LVEF)
  • Left ventricular size and wall thickness
  • Valve function 1
• B-type natriuretic peptide (BNP) or NT-proBNP measurement to help differentiate cardiac from non-cardiac causes of dyspnea 1

Additional Testing Based on Clinical Suspicion

• Coronary arteriography for patients with:
  • Angina or significant ischemia 1
  • Known or suspected coronary artery disease 1
• Screening for specific conditions when clinically indicated:
  • Hemochromatosis
  • Sleep-disordered breathing
  • HIV 1
• Diagnostic tests for rheumatologic diseases, amyloidosis, or pheochromocytoma when clinically suspected 1

Treatment Based on Heart Failure Stage

Staging System for Treatment Guidance

The ACC/AHA guidelines classify heart failure into four stages with specific treatment recommendations for each 1:

Stage A: At High Risk Without Structural Heart Disease

Patients with hypertension, atherosclerotic disease, diabetes, obesity, metabolic syndrome

• Treatment:
  • ACE inhibitor or ARB in appropriate patients
  • Control of risk factors (hypertension, diabetes)
  • Lifestyle modifications

Stage B: Structural Heart Disease Without Symptoms

Patients with previous MI, asymptomatic valvular disease, LV remodeling, low EF

• Treatment:
  • ACE inhibitor or ARB
  • Beta-blockers in appropriate patients
  • Consider ICD for selected patients

Stage C: Structural Heart Disease With Current or Prior Symptoms

• First-line pharmacotherapy 3:
  • ARNI (sacubitril-valsartan) as first-line therapy when possible
  • ACE inhibitors if ARNI not feasible
  • Beta-blockers (bisoprolol, carvedilol, metoprolol succinate)
  • Mineralocorticoid receptor antagonists (spironolactone, eplerenone)
  • SGLT2 inhibitors (dapagliflozin, empagliflozin)
  • Diuretics for fluid retention
  • Consider hydralazine/nitrates (especially in African American patients)

Stage D: Refractory Heart Failure Requiring Specialized Interventions

• Advanced therapies:
  • Biventricular pacing (CRT) for appropriate patients
  • Implantable defibrillators
  • Consider mechanical circulatory support or heart transplantation evaluation

Pharmacological Treatment Specifics

Recommended Medications and Dosing 3

• ARNI (Sacubitril/Valsartan):
  • Initial: 49/51 mg twice daily
  • Target: 97/103 mg twice daily
• ACE inhibitors:
  • Lisinopril: 2.5-5 mg daily → 20-40 mg daily
  • Enalapril: 2.5 mg twice daily → 10-20 mg twice daily
  • Ramipril: 1.25-2.5 mg daily → 10 mg daily
• Beta-blockers:
  • Bisoprolol: 1.25 mg daily → 10 mg daily
  • Carvedilol: 3.125 mg twice daily → 25-50 mg twice daily
  • Metoprolol succinate: 12.5-25 mg daily → 200 mg daily
• Mineralocorticoid receptor antagonists:
  • Spironolactone: 12.5-25 mg daily → 25-50 mg daily
  • Eplerenone: 25 mg daily → 50 mg daily
• SGLT2 inhibitors:
  • Dapagliflozin: 10 mg daily
  • Empagliflozin: 10 mg daily

Monitoring and Follow-up

• Regular monitoring of symptoms, urine output, renal function, and electrolytes 1
• Daily weight monitoring with action plan for weight gain >2 kg in 3 days 3
• Monitor renal function and potassium levels 1-2 weeks after starting therapy or dose changes 3
• Consider serial monitoring of natriuretic peptide levels to guide therapy 1, 3

Important Cautions and Contraindications

• Avoid dual RAS blockade (ACE inhibitor + ARB) due to increased risk of hyperkalemia 3
• Do not use ARNI within 36 hours of ACE inhibitor administration 3
• Avoid medications that can worsen heart failure:
  • NSAIDs and COX-2 inhibitors 1, 3
  • Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) 3
  • Class I antiarrhythmic agents 3
  • Thiazolidinediones (glitazones) 1

By following this systematic approach to diagnosis and treatment, clinicians can effectively manage patients with congestive heart failure to reduce morbidity and mortality while improving quality of life.