What is the management of heart failure?

Management of Heart Failure

The optimal management of heart failure requires quadruple therapy with SGLT2 inhibitors, beta-blockers, renin-angiotensin system inhibitors (preferably ARNI), and mineralocorticoid receptor antagonists to significantly reduce mortality and hospitalizations in patients with heart failure with reduced ejection fraction (HFrEF). 1

Pharmacological Management

First-Line Medications for HFrEF

1. Renin-Angiotensin System Inhibitors

   • ARNI (Sacubitril/Valsartan)

     • Preferred over ACE inhibitors
     • Starting dose: 49/51 mg twice daily
     • Target dose: 97/103 mg twice daily 1, 2
     • Contraindicated with concomitant ACE inhibitors or history of angioedema 2

   • ACE Inhibitors (if ARNI not tolerated)

     • Options: Lisinopril (2.5-5 mg → 20-40 mg daily), Enalapril (2.5 mg → 10-20 mg twice daily), Ramipril (1.25-2.5 mg → 10 mg daily) 1
     • High-quality evidence shows they reduce morbidity and increase survival 3

   • ARBs (if ACE inhibitors not tolerated)

     • Options: Candesartan (4-8 mg → 32 mg daily) 1
     • Reduce hospitalizations and improve quality of life 3

2. Beta-Blockers

   • Options: Bisoprolol (1.25 mg → 10 mg daily), Carvedilol (3.125 mg → 25-50 mg twice daily), Metoprolol succinate (12.5-25 mg → 200 mg daily) 1
   • High-quality evidence shows they reduce morbidity and increase survival 3
   • "Start low, go slow" approach with monitoring of heart rate, blood pressure, and clinical status 3
   • Consider for all patients with left ventricular systolic dysfunction, including older adults 3

3. Mineralocorticoid Receptor Antagonists (MRAs)

   • Options: Spironolactone (12.5-25 mg → 25-50 mg daily), Eplerenone (25 mg → 50 mg daily) 1
   • Require close monitoring of potassium levels and renal function 3

4. SGLT2 Inhibitors

   • Options: Dapagliflozin (10 mg daily), Empagliflozin (10 mg daily) 1
   • Recent addition to guideline-directed medical therapy

5. Diuretics

   • Used for symptom relief and fluid management
   • Not proven to reduce mortality but essential for managing congestion 3, 1

Second-Line/Additional Therapies

1. Hydralazine and Isosorbide Dinitrate

   • Consider for patients intolerant to both ACE inhibitors and ARBs 3
   • Particularly beneficial in specific populations 1

2. Cardiac Glycosides (Digoxin)

   • Indicated for atrial fibrillation with heart failure to control ventricular rate 3
   • Consider for patients with persistent symptoms despite optimal therapy 3, 1
   • Usual daily dose: 0.25-0.375 mg (0.125-0.25 mg in elderly) 3
   • Contraindicated in bradycardia, AV blocks, sick sinus syndrome, and electrolyte abnormalities 3

Device Therapy

1. Implantable Cardioverter-Defibrillator (ICD)

   • Consider for patients with LVEF ≤35% despite optimal medical therapy 1
   • Expected survival should be >1 year 1

2. Cardiac Resynchronization Therapy (CRT)

   • For symptomatic patients with QRS duration ≥150 msec and LBBB morphology 1
   • Can be considered according to NICE technology appraisal criteria 3

Heart Failure with Preserved Ejection Fraction (HFpEF)

• Limited specific therapies available
• Focus on treatment of comorbid conditions and diuretic therapy for fluid retention 3
• Rehabilitation should be offered despite limited evidence 3

Monitoring and Follow-up

1. Laboratory Monitoring

   • Check renal function and potassium levels before initiation and 1-2 weeks after starting therapy or dose changes 1
   • Monitor blood pressure, including postural changes 1

2. Self-Monitoring

   • Daily weight monitoring with action plan for weight gain >2 kg in 3 days 1
   • Self-monitoring of symptoms and fluid status 1

3. Medication Review

   • Review all medications at each visit
   • Avoid medications that worsen heart failure (NSAIDs, non-dihydropyridine calcium channel blockers) 1

Lifestyle Modifications

1. Sodium and Fluid Intake

   • Moderate sodium restriction to reduce fluid retention 1
   • Fluid restriction of 1.5-2 L/day in advanced heart failure 1

2. Physical Activity

   • Regular, structured aerobic exercise program starting with low intensity 1
   • Avoid heavy labor 1

3. Other Recommendations

   • Smoking cessation 1
   • Limited alcohol consumption (1-2 glasses of wine/day maximum) 1

Common Pitfalls and Caveats

1. Underdosing of Medications

   • ACE inhibitors and beta-blockers are often used at lower doses than tested in trials 4
   • Aim to titrate to target doses used in clinical trials 1

2. Medication Interactions

   • Avoid combining ARB with ACE inhibitor and MRA due to risk of renal dysfunction and hyperkalemia 1
   • Avoid NSAIDs and COX-2 inhibitors in all heart failure patients 1
   • Avoid thiazolidinediones (glitazones) in heart failure patients 1
   • Diltiazem/verapamil should be avoided in HFrEF patients 1

3. Beta-Blocker Initiation

   • Start with background ACE inhibition therapy
   • Patient should be relatively stable without need for intravenous inotropic therapy
   • Titrate slowly (dose may be doubled every 1-2 weeks if well tolerated)
   • Monitor for worsening heart failure, hypotension, or bradycardia 3