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, diuretics, and SGLT2 inhibitors, along with lifestyle modifications, patient education, and multidisciplinary care to reduce mortality, improve quality of life, and decrease hospitalizations. 1

Initial Assessment and Classification

• Determine heart failure type: heart failure with reduced ejection fraction (HFrEF, EF ≤40%) or heart failure with preserved ejection fraction (HFpEF, EF ≥50%) 1
• Assess severity of symptoms using New York Heart Association (NYHA) functional classification 1
• Identify etiology and precipitating factors of heart failure 1
• Evaluate for concomitant diseases relevant to heart failure management 1

Pharmacological Management

For HFrEF (EF ≤40%):

• First-line therapies:

  • ACE inhibitors (e.g., enalapril) - recommended as first-line therapy for patients with reduced LV systolic function 1, 2
  • Beta-blockers - shown to improve survival and reduce hospitalizations 1
  • Mineralocorticoid receptor antagonists (e.g., spironolactone) - for select patients with NYHA class III or IV heart failure 3
  • SGLT2 inhibitors - reduce cardiovascular death and heart failure hospitalizations 4
  • Diuretics - essential for symptomatic treatment when fluid overload is present 1

• Additional therapies:

  • Angiotensin receptor-neprilysin inhibitors (ARNIs) - can replace ACE inhibitors in appropriate patients 4
  • Ivabradine - for patients with heart rate ≥70 bpm despite maximum tolerated beta-blocker dose 5
  • Digoxin - to improve clinical symptoms, especially in patients with atrial fibrillation 3

For HFpEF (EF ≥50%):

• SGLT2 inhibitors and diuretics are first-line treatments 4
• Treat underlying conditions (hypertension, coronary artery disease, atrial fibrillation) 4

Non-Pharmacological Management

Patient Education and Self-Care

• Provide specific education about heart failure, symptoms recognition, and self-monitoring 1
• Teach patients to monitor symptoms and weight fluctuations daily 1
• Explain the importance of medication adherence and lifestyle modifications 1
• Encourage self-weighing and reporting weight gains of >2 kg in 3 days 1

Lifestyle Modifications

• Diet:

  • Moderate sodium restriction rather than strict reduction 6
  • Consider DASH diet which has shown benefits in heart failure patients 6
  • Avoid excessive fluid intake 1

• Physical Activity:

  • Regular physical activity is recommended for stable patients to prevent muscle deconditioning 1
  • Exercise training programs for stable NYHA class II-III patients 1, 7
  • Cardiac rehabilitation when appropriate 6

• Other Recommendations:

  • Smoking cessation 1
  • Limit alcohol consumption 6
  • Manage stress 1

Transitional and Team-Based Care

• Refer high-risk heart failure patients, particularly those with recurrent hospitalizations, to multidisciplinary heart failure disease management programs 1
• Provide patient-centered discharge instructions with a clear transitional care plan before hospital discharge 1
• Schedule early follow-up, generally within 7 days of hospital discharge 1
• Implement a transitional care plan addressing:
  • Precipitating causes of worsening heart failure
  • Medication adjustments and optimization
  • Diuretic management based on volume status
  • Coordination of laboratory monitoring
  • Reinforcement of education and assessment of compliance 1

Management of Acute Heart Failure

• Monitor heart rate, rhythm, blood pressure, and oxygen saturation continuously for at least the first 24 hours of admission 8
• Maintain oxygen saturation above 90% 8
• Consider inotropic support (dobutamine, milrinone) for patients with low cardiac output 8
• For right heart failure associated with pulmonary hypertension, consider pulmonary vasodilators 8
• Consider mechanical circulatory support in appropriate patients 8, 9

Special Considerations

• For right ventricular infarction, volume loading with normal saline may be necessary 8
• Avoid excessive fluid administration in patients with massively dilated right ventricle 8
• Before discharge, ensure the acute episode has resolved, congestion is absent, and a stable oral diuretic regimen has been established for at least 48 hours 8

Monitoring and Follow-up

• Regular assessment of symptoms, health status, and left ventricular function 4
• Timely referral to heart failure specialists for persistent advanced symptoms or worsening heart failure 4
• Monitor for and manage comorbidities (diabetes, ischemic heart disease, atrial fibrillation) 4

Common Pitfalls to Avoid

• Delaying initiation of disease-modifying therapies 4
• Inadequate diuresis in volume-overloaded patients 1
• Failure to uptitrate medications to target doses 1
• Neglecting patient education and self-care strategies 1
• Inadequate transitional care planning leading to early readmissions 1