What is the initial treatment for congestive heart failure?

Initial Treatment for Congestive Heart Failure

The initial treatment for congestive heart failure should include ACE inhibitors and diuretics, with ACE inhibitors as first-line therapy in patients with reduced left ventricular systolic function (ejection fraction <40-45%) and diuretics added when fluid overload is present. 1

First-Line Pharmacological Therapy

ACE Inhibitors

• Recommended as first-line therapy in patients with reduced left ventricular systolic function with or without symptoms 1
• Should be initiated at a low dose and gradually titrated to target doses shown effective in clinical trials 1
• Improves survival, symptoms, functional capacity, and reduces hospitalization in patients with moderate to severe heart failure 1
• In the absence of fluid retention, ACE inhibitors should be given as initial therapy 1

Diuretics

• Essential for symptomatic treatment when fluid overload is present (pulmonary congestion or peripheral edema) 1
• Provide rapid improvement of dyspnoea and increased exercise tolerance 1
• Loop diuretics or thiazides are recommended as initial diuretic treatment 1
• Should always be administered in combination with ACE inhibitors if possible 1
• If GFR <30 ml/min, thiazides should not be used except synergistically with loop diuretics 1

Recommended Procedure for Starting an ACE Inhibitor

1. Review the need for and dose of diuretics and vasodilators 1
2. Avoid excessive diuresis before treatment - reduce or withhold diuretics for 24 hours 1
3. Consider starting treatment in the evening when supine to minimize blood pressure effects 1
4. Start with a low dose and build up to recommended maintenance dosages 1
5. Monitor renal function regularly: before starting, 1-2 weeks after each dose increment, and at 3-6 month intervals 1
6. Avoid potassium-sparing diuretics during initiation of therapy 1
7. Avoid NSAIDs 1
8. Check blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment 1

Additional Therapies Based on Clinical Status

Beta-Blockers

• Recommended for all patients with stable mild, moderate, and severe heart failure with reduced LV ejection fraction (NYHA class II-IV) on standard treatment including diuretics and ACE inhibitors 1
• Should be added to the treatment regimen after stabilization with ACE inhibitors and diuretics 2

Aldosterone Antagonists (Spironolactone)

• Recommended in advanced heart failure (NYHA III-IV) in addition to ACE inhibition and diuretics 1
• Improves survival and reduces morbidity 1

Angiotensin II Receptor Blockers (ARBs)

• Should be considered in patients who do not tolerate ACE inhibitors (e.g., due to cough) 1
• May be less effective than ACE inhibitors for mortality reduction 1

Cardiac Glycosides (Digoxin)

• Indicated in atrial fibrillation with symptomatic heart failure to slow ventricular rate 1
• In sinus rhythm, recommended for patients with persistent heart failure symptoms despite ACE inhibitor and diuretic treatment 1

Common Pitfalls and Caveats

• Avoid excessive diuresis before starting ACE inhibitors as it may cause hypotension 1
• Monitor renal function closely, especially in patients with pre-existing renal dysfunction 1
• ACE inhibitor treatment is contraindicated in the presence of bilateral renal artery stenosis and angioedema during previous ACE inhibitor therapy 1
• Potassium-sparing diuretics should only be used if hypokalaemia persists despite ACE inhibition and diuretics 1
• Traditional heart failure therapy has included treatment of fluid retention with diuretics, although their effect on mortality has never been fully established 3

Non-Pharmacological Management

• Control sodium intake when necessary, especially in severe heart failure 1
• Avoid excessive fluids in severe heart failure 1
• Avoid excessive alcohol intake 1
• Exercise training programs are encouraged in stable patients in NYHA class II-III 1
• Self-monitoring including daily weighing is recommended 1