What is the initial management for patients with heart failure, particularly those with reduced ejection fraction?

Initial Management of Heart Failure with Reduced Ejection Fraction

For patients with heart failure with reduced ejection fraction (HFrEF), initial management should include ACE inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors as these medications have been proven to reduce mortality and improve quality of life. 1

Core Medication Strategy

First-Line Medications

• ACE inhibitors should be started within the first 24 hours if no contraindications are present, beginning with low doses and gradually titrating up 1
• Beta-blockers (specifically carvedilol, metoprolol succinate, or bisoprolol) should be initiated in all stable patients with HFrEF unless contraindicated 1
• Mineralocorticoid receptor antagonists (spironolactone) are recommended for NYHA Class III-IV heart failure to improve survival and reduce hospitalization 2
• SGLT2 inhibitors should be initiated in patients with established HFrEF to reduce cardiovascular events and mortality 1

Initiation and Titration Approach

• Start with low doses and gradually titrate up to target doses or maximum tolerated doses 1, 3
• Consider initiating one medication at a time with small increments, particularly in patients with low blood pressure 1
• For patients with very low blood pressure (SBP <90 mmHg), prioritize medications with less impact on blood pressure initially 1
• Monitor renal function, electrolytes, and blood pressure after each dose increment 1

Specific Medication Considerations

ACE Inhibitors

• Initial dosing should be low (e.g., lisinopril 2.5-5 mg daily) with gradual uptitration 1, 4
• Monitor for hypotension, renal dysfunction, and hyperkalemia 4
• In patients who cannot tolerate ACE inhibitors, angiotensin receptor blockers (ARBs) are an alternative 1
• For patients who tolerate ACE inhibitors/ARBs, consider switching to sacubitril/valsartan (ARNI) which provides additional mortality benefit 1

Beta-Blockers

• Start at low doses after patient is stabilized on ACE inhibitors 1
• Target beta-blockers with proven mortality benefit: carvedilol, metoprolol succinate, or bisoprolol 1
• Continue beta-blockers for at least 3 years after myocardial infarction 1
• If heart rate remains elevated (>70 bpm) despite beta-blockers, consider adding ivabradine in patients with sinus rhythm 1

Mineralocorticoid Receptor Antagonists

• Spironolactone has been shown to reduce mortality by 30% in NYHA Class III-IV heart failure 2
• Start with 25 mg daily and monitor potassium and renal function closely 2
• Particularly beneficial in patients with low baseline serum potassium 2

SGLT2 Inhibitors

• Add SGLT2 inhibitors with proven cardiovascular benefit regardless of diabetes status 1
• Can be initiated early in treatment as they have minimal impact on blood pressure 1

Special Considerations

Low Blood Pressure

• For patients with low baseline blood pressure, consider starting with SGLT2 inhibitors and MRAs as they have less impact on blood pressure 1
• Space out medications to reduce synergistic hypotensive effects 1
• Consider selective β₁ receptor blockers rather than non-selective beta-blockers with vasodilatory properties in patients with low blood pressure 1

Volume Management

• Diuretics should be used for symptomatic relief of fluid overload but do not have mortality benefit 1
• Adjust diuretic doses based on volume status to avoid overdiuresis which can worsen hypotension 1

Additional Therapies

• Consider hydralazine and isosorbide dinitrate in patients who cannot tolerate ACE inhibitors/ARBs 1
• Digoxin may be considered for symptom improvement in patients who remain symptomatic despite standard therapy 1
• Avoid routine use of calcium channel blockers and nitrates as they have not shown mortality benefit 1

Common Pitfalls to Avoid

• Failure to initiate all four pillars of therapy (ACE inhibitors/ARBs/ARNI, beta-blockers, MRAs, and SGLT2 inhibitors) 1
• Maintaining patients on initial low doses without attempting uptitration 1, 3
• Discontinuing medications due to asymptomatic changes in vital signs or laboratory values 1
• Overdiuresis leading to hypotension and renal dysfunction 1
• Delaying beta-blocker initiation in stable patients 1

By following this systematic approach to initiating and optimizing guideline-directed medical therapy, clinicians can significantly improve outcomes for patients with heart failure with reduced ejection fraction.