What is the management of heart failure?

Management of Heart Failure

The management of heart failure requires a comprehensive approach including pharmacological therapy with ACE inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors as the cornerstone treatments, along with diuretics for symptom management, device therapy when indicated, and structured patient education and follow-up. 1, 2

Classification of Heart Failure

Heart failure is classified based on ejection fraction:

• Heart failure with reduced ejection fraction (HFrEF): EF ≤40%
• Heart failure with preserved ejection fraction (HFpEF): EF ≥50% 1

Pharmacological Management

First-line Medications for HFrEF

1. ACE Inhibitors or ARBs

   • Recommended for all patients with HFrEF
   • Reduce mortality and hospitalizations
   • Start at low dose and titrate to target dose over 2-4 weeks 2, 3

2. Beta-Blockers

   • Recommended for all stable patients with HFrEF
   • Reduce mortality and improve symptoms
   • Should be used in addition to ACE inhibitors 2

3. Mineralocorticoid Receptor Antagonists (MRAs)

   • Recommended for patients with NYHA class II-IV HF with EF ≤35%
   • Monitor potassium and renal function closely 2

4. SGLT2 Inhibitors

   • Recommended for patients with heart failure regardless of ejection fraction
   • Reduce risk of hospitalization and cardiovascular death 2

5. Sacubitril/Valsartan (ARNI)

   • Indicated to reduce cardiovascular death and hospitalization in HFrEF
   • Starting dose: 49/51 mg twice daily
   • Target dose: 97/103 mg twice daily
   • Requires 36-hour washout period when switching from ACE inhibitor 3

6. Diuretics

   • Essential for symptomatic treatment of fluid overload
   • Should be administered with ACE inhibitors when possible
   • Monitor for electrolyte abnormalities and dehydration 1, 2

Additional Pharmacological Options

• Hydralazine and isosorbide dinitrate: Alternative for patients who cannot tolerate ACE inhibitors/ARBs 1
• Digoxin: May improve symptoms, especially in patients with atrial fibrillation 4

Device Therapy

1. Cardiac Resynchronization Therapy (CRT)

   • Consider for patients with LVEF <35% and QRS duration ≥150 ms or 120-149 ms with mechanical dyssynchrony 2

2. Implantable Cardioverter-Defibrillator (ICD)

   • Consider for patients with LVEF <35% (or <30% with QRS ≥120 ms) for prevention of sudden cardiac death 2

Non-Pharmacological Management

Patient Education

• Provide specific education to facilitate self-care 1
• Explain heart failure pathophysiology, symptom recognition, and medication adherence
• Teach self-monitoring of weight and symptoms 1

Lifestyle Modifications

1. Sodium Restriction

   • Reasonable for patients with symptomatic HF to reduce congestive symptoms
   • Moderate restriction is better than strict reduction 1, 2, 5

2. Exercise and Physical Activity

   • Encourage moderate dynamic exercise (walking, recreational biking)
   • Avoid isometric exercise
   • Consider supervised exercise-based rehabilitation programs for stable patients 2, 5

3. Weight Management

   • Address obesity as it's a risk factor for heart failure progression 1, 6

4. Smoking Cessation

   • Strongly advise patients who smoke to quit 1

5. Alcohol Limitation

   • Moderate alcohol intake (except in alcoholic cardiomyopathy where it's prohibited) 2

Transitional Care and Follow-up

1. Discharge Planning

   • Provide patient-centered discharge instructions with clear transitional care plan
   • Early follow-up within 7 days of hospital discharge 1

2. Multidisciplinary Care

   • Refer high-risk HF patients to multidisciplinary disease management programs
   • Team may include cardiologists, primary care clinicians, HF nurses, pharmacists, dieticians, and social workers 1

3. Regular Monitoring

   • Monitor symptoms, weight, volume status
   • Adjust medications as needed
   • Laboratory monitoring of renal function and electrolytes, especially with ACE inhibitors, ARBs, and MRAs 2

Advanced Heart Failure Management

1. Palliative Care

   • Consider advance care planning for patients with advanced heart failure
   • Focus on symptom management (dyspnea, fatigue, pain, depression, anxiety) 2

2. Mechanical Circulatory Support and Transplantation

   • Consider for appropriate candidates with end-stage heart failure 2

Common Pitfalls and Caveats

• Medication Interactions: Avoid concomitant use of ACE inhibitors with ARNIs (require 36-hour washout) 3
• Electrolyte Monitoring: Close monitoring of potassium and renal function with RAAS inhibitors is essential 2
• NSAIDs: Avoid in heart failure patients as they can worsen renal function and fluid retention 3
• Inadequate Diuresis: Insufficient diuresis can lead to persistent congestion and symptoms
• Failure to Titrate: Many patients remain on suboptimal doses of evidence-based medications

By following this structured approach to heart failure management, focusing on evidence-based pharmacological therapy, appropriate device therapy when indicated, and comprehensive patient education and follow-up, clinicians can effectively reduce mortality, hospitalizations, and improve quality of life for patients with heart failure.