What are the treatments for heart failure?

Treatments for Heart Failure

The cornerstone of heart failure treatment includes ACE inhibitors, beta-blockers, diuretics, aldosterone antagonists, and ARBs, with therapy tailored based on heart failure severity and left ventricular ejection fraction. 1

First-Line Pharmacological Therapy

• ACE inhibitors are recommended as first-line therapy in patients with reduced left ventricular systolic function 1
• Diuretics are essential for symptomatic treatment when fluid overload is present (pulmonary congestion or peripheral edema) 1
• Beta-blocking agents are recommended for all patients with stable mild, moderate, and severe heart failure with reduced LV ejection fraction in NYHA class II-IV on standard treatment 1

Medication-Specific Recommendations

ACE Inhibitors

• Start with a low dose and build up to recommended maintenance dosages 1
• Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, and subsequently at 6-month intervals 1
• Avoid excessive diuresis before starting treatment; reduce or withhold diuretics for 24 hours if possible 1
• Avoid NSAIDs during ACE inhibitor therapy 1

Diuretics

• Loop diuretics or thiazides are first-line for fluid retention 1
• Always administer diuretics in combination with ACE inhibitors if possible 1
• If GFR < 30 ml/min, avoid thiazides except when prescribed synergistically with loop diuretics 1
• For insufficient response, increase diuretic dose or combine loop diuretics and thiazides 1
• With persistent fluid retention, administer loop diuretics twice daily 1

Beta-Blockers

• Start with a very low dose and titrate up to maintenance dosages 1
• Patients should be on background ACE inhibitor therapy if not contraindicated 1
• The patient should be in relatively stable condition without need for intravenous inotropic therapy 1
• Monitor for heart failure symptoms, fluid retention, hypotension, and bradycardia during titration 1

Aldosterone Receptor Antagonists

• Spironolactone is recommended in advanced heart failure (NYHA III-IV) in addition to ACE inhibition and diuretics 1
• Check serum potassium (<5.0 mmol) and creatinine (<250 mmol) before starting 1
• Start with 25 mg spironolactone daily and check electrolytes after 4-6 days 1
• If serum potassium ≥5.5 mmol/L, reduce dose by 50%; stop if potassium remains ≥5.5 mmol/L 1

Angiotensin II Receptor Antagonists (ARBs)

• Consider in patients who do not tolerate ACE inhibitors for symptomatic treatment 1
• May improve heart failure symptoms and reduce hospitalizations when combined with ACE inhibitors 1
• Have significantly fewer side effects (notably cough) than ACE inhibitors 1

Cardiac Glycosides

• Indicated in atrial fibrillation with any degree of symptomatic heart failure to slow ventricular rate 1
• In sinus rhythm, digoxin improves clinical status in patients with persistent symptoms despite ACE inhibitor and diuretic treatment 1
• The usual daily dose of oral digoxin is 0.25-0.375 mg if serum creatinine is normal (elderly: 0.125-0.25 mg) 1
• Contraindicated in bradycardia, AV-block, sick sinus syndrome, carotid sinus syndrome, hypokalemia, and hypercalcemia 1

Newer Therapies

• Sacubitril-valsartan has shown benefits in reducing heart failure hospitalizations in patients with reduced ejection fraction 2

Non-Pharmacological Management

• Explain heart failure pathophysiology, symptoms recognition, and self-management to patients 1
• Encourage daily physical and leisure activities in stable patients to prevent muscle deconditioning 1
• Control sodium intake when necessary, especially in severe heart failure 1
• Avoid excessive fluids in severe heart failure 1
• Avoid excessive alcohol intake 1
• Consider exercise training programs in stable NYHA II-III patients 1

Treatment Based on Heart Failure Severity

NYHA Class II (Mild Heart Failure)

• ACE inhibitor titrated to recommended target doses 1
• Add beta-blocker and titrate to target dosages 1
• Diuretics may be necessary during episodes of fluid overload 1

NYHA Class III-IV (Moderate to Severe Heart Failure)

• Diuretics plus ACE inhibitors 1
• Add beta-blockers 1
• Add spironolactone for advanced heart failure 1
• Consider cardiac glycosides if symptoms persist 1
• For end-stage heart failure (persistent NYHA IV), consider heart transplantation or palliative care 1

Common Pitfalls and Caveats

• Avoid potassium-sparing diuretics during initiation of ACE inhibitor therapy 1
• Monitor for hypotension when starting ACE inhibitors or beta-blockers 1
• Do not use beta-blockers in patients with asthma, severe bronchial disease, or symptomatic bradycardia/hypotension 1
• Routine inotropic therapy increases mortality and should be reserved for severe episodes of heart failure 1
• Patients with right heart failure may require different management strategies, including consideration of pulmonary vasodilators 3