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 a combination of ACE inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors as these medications have proven mortality benefits and should be initiated as soon as possible. 1

Core Medication Therapy

First-Line Medications

• Renin-Angiotensin System Inhibitors: ACE inhibitors (or ARBs if ACE inhibitors not tolerated) should be started within the first 24 hours if no contraindications exist 1

  • Start with low doses (e.g., lisinopril 5 mg daily) and gradually titrate up 1, 2
  • Consider transitioning to sacubitril/valsartan (ARNI) when stable on ACE inhibitor/ARB 1

• Beta-Blockers: Recommended for all patients with stable HFrEF (NYHA class II-IV) 1

  • Use beta-blockers with proven mortality benefit: carvedilol, metoprolol succinate, or bisoprolol 1
  • Start at low dose after patient is stable and not in acute decompensation 3
  • Selective β₁ blockers may be preferred in patients with lower blood pressure 1

• Mineralocorticoid Receptor Antagonists (MRAs): Spironolactone is indicated for NYHA Class III-IV HFrEF 1, 4

  • Initial dose of 25 mg daily, may decrease to 25 mg every other day if not tolerated 4
  • Proven to reduce mortality by 30% in patients with advanced heart failure 4
  • Monitor serum potassium and renal function closely 1

• SGLT2 Inhibitors: Should be initiated in patients with established HFrEF 1

  • Recommended for patients with eGFR >20 ml/min/1.73 m² 1
  • Minimal impact on blood pressure compared to other HF medications 1

Diuretics

• Loop diuretics or thiazides for fluid overload and symptom management 1
• Not proven to reduce mortality but essential for symptom control 1
• Should be administered in addition to ACE inhibitors 1
• If GFR <30 ml/min, avoid thiazides except when used synergistically with loop diuretics 1

Medication Initiation and Titration Strategy

Sequencing Approach

1. Start with diuretics for patients with fluid overload to achieve euvolemia 1, 3
2. Begin ACE inhibitor at low dose (or ARB if ACE inhibitor not tolerated) 1
3. Add beta-blocker once patient is stable (not during acute decompensation) 1, 3
4. Add MRA (spironolactone) for patients with NYHA class III-IV symptoms 1, 4
5. Add SGLT2 inhibitor regardless of diabetes status 1
6. Consider transitioning from ACE inhibitor/ARB to sacubitril/valsartan when stable 1

Titration Principles

• Use a "start low, go slow" approach with small increments 1, 5
• Up-titrate one drug at a time with close monitoring 1
• Target doses used in clinical trials, but recognize that benefits occur even at lower doses 5
• Monitor blood pressure, heart rate, renal function, and electrolytes after each dose increase 1
• Space out medications to minimize hypotensive effects 1

Special Considerations

Low Blood Pressure Management

• If systolic BP <90 mmHg and symptomatic, prioritize medications with less BP-lowering effect 1
• SGLT2 inhibitors and MRAs have minimal impact on BP and can be prioritized 1, 6
• Consider selective beta-blockers (metoprolol, bisoprolol) over non-selective ones (carvedilol) if BP is low 1
• For patients with low BP but HR >70 bpm, consider ivabradine if in sinus rhythm 1

Renal Function Concerns

• If eGFR <30 ml/min, adjust medication selection and dosing 1
• Monitor creatinine and potassium closely with ACE inhibitors and MRAs 1
• Avoid potassium-sparing diuretics during ACE inhibitor initiation 1

Cardiac Rhythm Issues

• For patients with atrial fibrillation, digoxin is indicated to control ventricular rate 1
• Beta-blockers should be continued for at least 3 years after myocardial infarction 1

Common Pitfalls to Avoid

• Undertreatment: Many patients remain on suboptimal doses or don't receive all four pillars of therapy 1
• Excessive diuresis: Can lead to hypotension and impaired renal function 1
• Medication interactions: Avoid NSAIDs as they can worsen renal function and counteract HF medications 1
• Focusing on symptoms alone: Mortality benefits occur even before symptom improvement 5
• Delaying therapy: Early initiation of life-saving medications is critical, even if at lower doses 5
• Abandoning therapy due to mild side effects: Temporary side effects often resolve with continued treatment 1

By following this evidence-based approach to medication initiation and titration, clinicians can optimize outcomes for patients with HFrEF, focusing on the proven mortality and morbidity benefits of these cornerstone therapies.