What is the recommended treatment for heart failure?

Heart Failure Treatment

The recommended treatment for heart failure includes ACE inhibitors as first-line therapy, along with diuretics for symptomatic relief, beta-blockers for all stable patients, and aldosterone antagonists for advanced heart failure, with careful monitoring of renal function and electrolytes throughout therapy. 1

First-Line Pharmacological Therapy

• ACE inhibitors are recommended as first-line therapy in patients with reduced left ventricular systolic function (reduced ejection fraction) 1
• Start with a low dose and gradually titrate up to target maintenance doses shown to be effective in clinical trials 1
• For heart failure, lisinopril should be started at 5 mg once daily (2.5 mg in patients with hyponatremia) and titrated up to a maximum of 40 mg daily 2
• High doses of ACE inhibitors (such as lisinopril 32.5-35 mg daily) have shown greater benefits in reducing hospitalizations compared to low doses (2.5-5 mg daily) 3, 4

Diuretic Therapy

• Diuretics are essential for symptomatic treatment when fluid overload is present (pulmonary congestion or peripheral edema) 1
• Loop diuretics or thiazides should always be administered in addition to an ACE inhibitor 1
• For patients with GFR < 30 ml/min, avoid thiazides except when used synergistically with loop diuretics 1
• If response is insufficient, increase diuretic dose or combine loop diuretics with thiazides 1
• For persistent fluid retention, administer loop diuretics twice daily or add metolazone in severe heart failure cases (with frequent monitoring of creatinine and electrolytes) 1

Beta-Adrenoceptor Antagonists (Beta-Blockers)

• Beta-blockers are recommended for all patients with stable mild, moderate, and severe heart failure with reduced LV ejection fraction (NYHA class II-IV) who are already on standard treatment including diuretics and ACE inhibitors 1
• Beta-blockers reduce hospitalizations, improve functional class, and prevent worsening of heart failure 1
• In patients with LV systolic dysfunction following acute myocardial infarction, long-term beta-blockade is recommended in addition to ACE inhibition to reduce mortality 1

Aldosterone Receptor Antagonists

• Spironolactone is recommended in advanced heart failure (NYHA III-IV) in addition to ACE inhibition and diuretics to improve survival and reduce morbidity 1
• Spironolactone is indicated for NYHA Class III-IV heart failure with reduced ejection fraction to increase survival, manage edema, and reduce hospitalization 5
• Monitor serum potassium and creatinine carefully when initiating therapy and during dose adjustments 1

Angiotensin II Receptor Blockers (ARBs)

• ARBs should be considered in patients who cannot tolerate ACE inhibitors due to side effects such as cough 1
• In combination with ACE inhibitors, ARBs may improve heart failure symptoms and reduce hospitalizations for worsening heart failure 1
• Side effects, notably cough, are significantly less with ARBs than with ACE inhibitors 1

Cardiac Glycosides

• Digoxin is indicated for patients with atrial fibrillation and symptomatic heart failure to slow ventricular rate and improve ventricular function 1
• In sinus rhythm, digoxin is recommended for patients with persisting heart failure symptoms despite ACE inhibitor and diuretic treatment 1
• A combination of digoxin and beta-blockade appears superior to either agent alone 1
• The usual daily dose of oral digoxin is 0.25-0.375 mg if serum creatinine is normal (0.125-0.25 mg in elderly patients) 1

Non-Pharmacological Measures

• Provide patient education about heart failure, symptom recognition, and self-management 1
• Recommend daily physical activity in stable patients to prevent muscle deconditioning 1
• Control sodium intake when necessary, especially in patients with severe heart failure 1
• Avoid excessive fluid intake in severe heart failure 1
• Avoid excessive alcohol consumption 1
• Encourage daily weight monitoring and reporting significant changes 1

Common Pitfalls and Monitoring

• When starting ACE inhibitors, avoid excessive diuresis before treatment; consider reducing or withholding diuretics for 24 hours 1
• Avoid potassium-sparing diuretics during initiation of ACE inhibitor therapy 1
• Avoid NSAIDs and COX-2 inhibitors as they increase the risk of heart failure worsening 1, 6
• Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment of ACE inhibitors, at 3 months, and subsequently at 6-month intervals 1
• For patients transitioning from hospital to home, provide comprehensive discharge instructions and consider enrollment in a multidisciplinary care management program 6