What is the initial management for patients with heart failure?

Initial Management of Heart Failure

The initial management of heart failure should include ACE inhibitors and beta-blockers as first-line therapy for all patients with heart failure with reduced ejection fraction (HFrEF), regardless of symptom severity, as these medications have been proven to reduce morbidity and mortality. 1, 2

Diagnosis and Assessment

• Upon presentation, measurement of plasma natriuretic peptide levels (BNP, NT-proBNP, or MR-proANP) is recommended in all patients with acute dyspnea and suspected heart failure to help differentiate heart failure from non-cardiac causes of dyspnea 1
• Immediate ECG and echocardiography are recommended in all patients with suspected cardiogenic shock 1
• All patients with cardiogenic shock should be rapidly transferred to a tertiary care center with 24/7 cardiac catheterization service and dedicated ICU/CCU with availability of short-term mechanical circulatory support 1

Pharmacological Management

First-Line Therapy

• ACE inhibitors should be initiated in all patients with HFrEF to improve symptoms and reduce mortality 1, 2

  • 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 if possible 1
  • Start with a low dose and build up to recommended maintenance dosages 1

• Beta-blockers should be initiated in all patients with HFrEF, including older adults and those with comorbidities such as peripheral vascular disease, erectile dysfunction, diabetes, and pulmonary disease 1, 2

  • Use a "start-low, go-slow" approach, monitoring heart rate, blood pressure, and clinical status after each dose titration 1
  • Recommended beta-blockers for heart failure include bisoprolol, metoprolol succinate, carvedilol, and nebivolol 1
  • For heart failure patients, metoprolol succinate should be started at 25 mg once daily for NYHA Class II and 12.5 mg once daily for more severe heart failure 3

• Diuretics should be administered for symptom relief in patients with fluid retention 1, 2

  • In patients with new-onset acute heart failure or decompensated chronic heart failure not receiving oral diuretics, the initial recommended dose should be 20-40 mg IV furosemide (or equivalent) 1
  • For those on chronic diuretic therapy, initial IV dose should be at least equivalent to oral dose 1
  • Regular monitoring of symptoms, urine output, renal function, and electrolytes is essential during IV diuretic use 1

Second-Line Therapy Options

• Mineralocorticoid receptor antagonists (MRAs) such as spironolactone are recommended in advanced heart failure (NYHA III-IV) to improve survival and morbidity 1, 2
• Angiotensin II receptor blockers (ARBs) could be considered in patients who do not tolerate ACE inhibitors 1
• Combination therapy with hydralazine and nitrates may be considered, particularly beneficial in African American patients 1, 2

Non-Pharmacological Management

• Regular aerobic exercise is recommended for all stable patients with heart failure to improve functional capacity, symptoms, and reduce the risk of hospitalization 1
• Enrollment in a multidisciplinary care management program is recommended to reduce the risk of heart failure hospitalization and mortality 1, 2
• Patient education should include self-weighing, rationale of treatments, importance of medication adherence, and smoking cessation 1

Advanced Therapies

• Cardiac resynchronization therapy (CRT) is recommended for symptomatic patients with heart failure in sinus rhythm with QRS duration ≥150 msec and LBBB QRS morphology and with LVEF ≤35% despite optimal medical therapy 1
• For patients with refractory heart failure (Stage D), consider mechanical circulatory support, heart transplantation, or palliative care 2

Treatments to Avoid

• Inotropic agents are not recommended unless the patient is symptomatically hypotensive or hypoperfused due to safety concerns 1
• Thiazolidinediones (glitazones) are not recommended as they increase the risk of heart failure worsening and hospitalization 1
• NSAIDs or COX-2 inhibitors should be avoided as they increase the risk of heart failure worsening and hospitalization 1
• Adaptive servo-ventilation is not recommended in patients with HFrEF and predominant central sleep apnea due to increased mortality risk 1

Implementation Challenges and Solutions

• Despite compelling evidence for ACE inhibitors and beta-blockers, these therapies remain underused in clinical practice 4, 5
• Early initiation of beta-blockers before hospital discharge has been shown to be safe and effective, improving post-discharge medication adherence 4
• Hospital-based management systems with pre-discharge initiation of evidence-based therapies have demonstrated reduced mortality and hospitalization rates 4, 5