What is the recommended treatment for heart failure?

Treatment for Heart Failure

The recommended first-line treatment for heart failure with reduced ejection fraction (HFrEF) includes an ACE inhibitor, a beta-blocker, and a mineralocorticoid receptor antagonist (MRA), with the addition of sacubitril/valsartan and SGLT2 inhibitors in appropriate patients to reduce mortality and hospitalizations. 1, 2, 3

Pharmacological Treatment Algorithm

First-Line Therapy

• ACE inhibitors are recommended as first-line therapy in patients with reduced left ventricular systolic function, starting with a low dose and gradually titrating up to target maintenance doses 1, 2
• Beta-blockers should be added for all stable patients with mild, moderate, and severe heart failure with reduced ejection fraction (NYHA class II-IV) who are already on standard treatment including diuretics and ACE inhibitors 1, 2
• Mineralocorticoid receptor antagonists (MRAs) are recommended for patients who remain symptomatic despite treatment with an ACE inhibitor and a beta-blocker to reduce the risk of heart failure hospitalization and death 1

Additional Therapy for Symptomatic Patients

• 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 1, 2
• Sacubitril/valsartan is recommended as a replacement for an ACE inhibitor in ambulatory patients with HFrEF who remain symptomatic despite optimal treatment with an ACE inhibitor, a beta-blocker, and an MRA 1, 4
• SGLT2 inhibitors have shown benefits in reducing cardiovascular mortality and heart failure hospitalizations regardless of diabetes status 5, 3

Device Therapy

• Implantable cardioverter defibrillators (ICDs) are recommended to reduce the risk of sudden death and all-cause mortality in:
  • Patients who have recovered from ventricular arrhythmia causing hemodynamic instability 1
  • Patients with symptomatic HF (NYHA Class II-III) and LVEF ≤35% despite optimal medical therapy for at least 3 months 1
• Cardiac resynchronization therapy (CRT) is recommended for symptomatic heart failure patients in sinus rhythm with QRS duration ≥150 msec, LBBB QRS morphology, and LVEF ≤35% 1

Monitoring and Dose Adjustment

• When starting ACE inhibitors:
  • Review the need for and dose of diuretics and vasodilators 1
  • Avoid excessive diuresis before treatment; reduce or withhold diuretics for 24 hours 1, 2
  • Start with a low dose and build up to recommended maintenance dosages 1, 2
  • Check blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, and subsequently at 6-month intervals 1, 2

Special Considerations

• Reduce starting dose to half the usually recommended dose for patients with:
  • Severe renal impairment 4
  • Moderate hepatic impairment 4
• Avoid diltiazem or verapamil in patients with HFrEF as they increase the risk of heart failure worsening 1
• Avoid the combination of an ACE inhibitor, ARB, and MRA due to increased risk of renal dysfunction and hyperkalemia 1
• ICD implantation is not recommended within 40 days of an MI as it does not improve prognosis 1

Non-Pharmacological Measures

• Provide patient education about heart failure, symptom recognition, and self-management 1, 2
• Recommend daily physical activity in stable patients to prevent muscle deconditioning 1, 2
• Control sodium intake when necessary, especially in patients with severe heart failure 1, 2
• Avoid excessive fluid intake in severe heart failure 1, 2

Common Pitfalls to Avoid

• Underutilization of ACE inhibitors or using doses lower than those found efficacious in trials 6
• Failure to titrate medications to target doses shown to be effective in clinical trials 2, 6
• Avoiding ACE inhibitors in patients presumed to be at higher risk (low blood pressure, elevated creatinine, elderly, diabetics) when most can actually tolerate them 6
• Adding an ARB (or renin inhibitor) to the combination of an ACE inhibitor and an MRA, which increases risk of renal dysfunction and hyperkalemia 1

The PARADIGM-HF trial demonstrated that sacubitril/valsartan was superior to enalapril in reducing the risk of cardiovascular death or heart failure hospitalization (HR 0.80; 95% CI, 0.73,0.87) and improved overall survival (HR 0.84; 95% CI [0.76,0.93]) 4, making it an important option for patients who remain symptomatic despite standard therapy.