What is the management and treatment of heart failure?

Heart Failure Management and Treatment

The cornerstone of heart failure management includes ACE inhibitors as first-line therapy for patients with reduced left ventricular systolic function, along with beta-blockers, diuretics for fluid overload, and aldosterone antagonists for advanced heart failure, all of which have been shown to improve survival and reduce hospitalizations. 1, 2

Definition and Initial Assessment

• Heart failure is a clinical syndrome characterized by the heart's inability to provide sufficient blood flow to meet metabolic requirements or accommodate systemic venous return 3
• Classification should be determined as heart failure with reduced ejection fraction (HFrEF, EF ≤40%) or heart failure with preserved ejection fraction (HFpEF, EF ≥50%) 1
• Assess severity using New York Heart Association (NYHA) functional classification to guide treatment decisions 1
• Identify etiology and precipitating factors of heart failure, which may include ischemic heart disease, hypertension, diabetes, cardiomyopathies, valvular disease, or cardiotoxic drugs 3, 1

Pharmacological Management

First-Line Therapies

• ACE inhibitors are recommended as first-line therapy in patients with reduced LV systolic function 2, 1
• Start with a low dose and build up to recommended maintenance dosages shown to be effective in large trials 2
• Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, and subsequently at 6-month intervals 2

Diuretics

• Diuretics are essential for symptomatic treatment when fluid overload is present (pulmonary congestion or peripheral edema) 2
• Loop diuretics (e.g., furosemide) are first-line therapy for managing fluid retention 4
• For insufficient response, increase the dose of diuretic or combine loop diuretics and thiazides 2
• In severe chronic heart failure with persistent fluid retention, administer loop diuretics twice daily or add metolazone with frequent measurement of creatinine and electrolytes 2

Beta-Blockers

• 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 2
• In patients with LV systolic dysfunction following an acute myocardial infarction, long-term beta-blockade is recommended in addition to ACE inhibition to reduce mortality 2

Aldosterone Antagonists

• Spironolactone is indicated for treatment of NYHA Class III-IV heart failure with reduced ejection fraction to increase survival, manage edema, and reduce hospitalization 5
• Aldosterone antagonism is recommended in advanced heart failure (NYHA III-IV), in addition to ACE inhibition and diuretics to improve survival and morbidity 2
• Monitor potassium and renal function closely when initiating therapy 5

Newer Therapies

• Combined angiotensin receptor blocker neprilysin inhibitors (ARNIs) have been associated with improvements in hospital admissions and mortality compared to ACE inhibitors alone 6
• Guidelines now recommend substitution of ACE inhibitors or ARBs with ARNIs in appropriate patients 6

Non-Pharmacological Management

Dietary Measures

• Control sodium intake when necessary, especially in patients with severe heart failure 2
• Fluid restriction of 1.5–2 L/day is advised in advanced heart failure 2
• Moderate alcohol intake (one beer, 1–2 glasses of wine/day) is permitted except in alcoholic cardiomyopathy, where it is prohibited 2

Physical Activity and Lifestyle

• Daily physical and leisure activities in stable patients to prevent muscle deconditioning 2
• Exercise training programs are recommended for stable NYHA II-III patients 2
• Rest is not encouraged in stable conditions 2

Patient Education

• Explain what heart failure is, its causes, and how to recognize symptoms 2
• Teach self-weighing and reporting weight gains of >2 kg in 3 days 1
• Emphasize the importance of medication adherence and lifestyle modifications 1

Management of Acute/Worsening Heart Failure

• Monitor heart rate, rhythm, blood pressure, and oxygen saturation continuously for at least the first 24 hours of admission 4
• Maintain oxygen saturation above 90% at all times 4
• Consider inotropic support for patients with low cardiac output:
  • Dobutamine at 2.5-5.0 μg/kg/min can improve right ventricular output 4
  • Milrinone (0.25-0.75 μg/kg/min) is an alternative, particularly for its additional pulmonary vasodilatory effects 4
• Pulmonary artery catheterization should be considered in patients who are refractory to pharmacological treatment 4

Transitional and Team-Based Care

• Schedule early follow-up, generally within 7 days of hospital discharge 1
• Before discharge, ensure the acute episode of heart failure has resolved, congestion is absent, and a stable oral diuretic regimen has been established for at least 48 hours 4
• Refer high-risk heart failure patients to multidisciplinary heart failure disease management programs 1

Common Pitfalls to Avoid

• Inadequate diuresis in volume-overloaded patients 1
• Failure to uptitrate medications to target doses 1
• Use of medications that may worsen heart failure, including:
  • Non-steroidal anti-inflammatory drugs (NSAIDs) and coxibs 2
  • Class I anti-arrhythmic agents 2
  • Calcium antagonists (verapamil, diltiazem, and short-acting dihydropyridine derivatives) 2
  • Tricyclic anti-depressants, corticosteroids, and lithium 2
• Neglecting patient education and self-care strategies 1
• Inadequate transitional care planning leading to early readmissions 1