What is the treatment for chronic heart failure?

Treatment of Chronic Heart Failure

The treatment of chronic heart failure requires a comprehensive approach including ACE inhibitors as first-line therapy, beta-blockers, diuretics for fluid overload, and additional therapies based on disease severity and patient characteristics. 1, 2

Core Pharmacological Therapy

First-Line Medications

• ACE inhibitors are recommended as first-line therapy in patients with reduced left ventricular systolic function to improve survival and quality of life 1
• Beta-blockers are recommended for all patients with stable mild, moderate, and severe heart failure with reduced ejection fraction 1, 2
• Diuretics are essential for symptomatic treatment when fluid overload is present (pulmonary congestion or peripheral edema) and should be administered in combination with ACE inhibitors when possible 1
• SGLT2 inhibitors are now considered part of core therapy with proven mortality benefit in both HFrEF and HFpEF 2

Diuretic Management

• Loop diuretics or thiazides should be used as initial diuretic treatment 1
• For insufficient response, increase diuretic dose or combine loop diuretics and thiazides 1
• In severe chronic heart failure with persistent fluid retention, administer loop diuretics twice daily or add metolazone with frequent monitoring of creatinine and electrolytes 1
• Potassium-sparing diuretics should only be used if hypokalaemia persists after initiation of therapy with ACE inhibitors and diuretics 1

Advanced Pharmacological Options

• Angiotensin receptor-neprilysin inhibitors (sacubitril/valsartan) are indicated to reduce the risk of cardiovascular death and hospitalization for heart failure in adults with chronic heart failure and reduced ejection fraction 3
• Mineralocorticoid receptor antagonists (MRAs) are recommended for patients with recent or current severe symptoms, with careful monitoring of potassium and renal function 2
• Consider hydralazine and isosorbide dinitrate for patients who cannot tolerate ACE inhibitors/ARBs due to hypotension or renal insufficiency, particularly beneficial in African American patients 2, 4

Non-Pharmacological Management

• Patient education is crucial and should include explanation of heart failure, symptom recognition, self-weighing, and the importance of medication adherence 1
• Physical activity should be encouraged in stable patients to prevent muscle deconditioning 1
• Exercise training programs are beneficial for stable NYHA class II-III patients 1, 2
• Sodium intake should be controlled, particularly in patients with severe heart failure 1
• Excessive fluid intake should be avoided in severe heart failure 1
• Excessive alcohol consumption should be avoided 1

Practical Implementation of ACE Inhibitor Therapy

1. Review the need for and dose of diuretics and vasodilators before starting ACE inhibitors 1
2. Reduce or withhold diuretics for 24 hours before initiating ACE inhibitors 1
3. Start with a low dose and gradually increase to recommended maintenance dosages 1
4. Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, and subsequently at 6-month intervals 1
5. Avoid potassium-sparing diuretics during initiation of ACE inhibitor therapy 1
6. Avoid NSAIDs which can interfere with ACE inhibitor efficacy 1

Management of Advanced Heart Failure

• For refractory heart failure (Stage D), consider mechanical circulatory support, heart transplantation, or palliative care 2
• Inotropic support with dobutamine (2.5-5.0 μg/kg/min) may be considered for right ventricular dysfunction 5
• Pulmonary vasodilators may be beneficial in heart failure associated with pulmonary hypertension 5

Common Pitfalls and Caveats

• Avoid excessive diuresis before initiating ACE inhibitors as it may lead to hypotension 1
• Monitor renal function closely after starting ACE inhibitors, particularly in patients with pre-existing renal impairment 1
• Avoid long-term use of positive inotropic drugs and calcium channel blockers for routine treatment of heart failure 2
• When switching from an ACE inhibitor to sacubitril/valsartan, allow a washout period of 36 hours between medications to prevent angioedema 3
• Be vigilant for hyperkalemia when using ACE inhibitors, ARBs, or aldosterone antagonists, especially in patients with renal dysfunction 6

Treatment Goals

The primary aims of heart failure treatment are:

• Prevention and control of diseases leading to cardiac dysfunction 1
• Maintenance or improvement in quality of life 1
• Improved survival 1