What is the initial management for patients with heart failure?

Initial Management of Heart Failure

The initial management for patients with heart failure should include ACE inhibitors and beta-blockers as first-line therapy, regardless of symptom severity, along with diuretics for symptomatic relief of fluid retention. 1

Diagnosis and Assessment

• Upon presentation with suspected heart failure, measurement of plasma natriuretic peptide levels (BNP, NT-proBNP or MR-proANP) is recommended to help differentiate heart failure from non-cardiac causes of dyspnea 1
• Immediate ECG and echocardiography are recommended for all patients with suspected heart failure to assess structural abnormalities and ejection fraction 1
• Regular monitoring of symptoms, urine output, renal function, and electrolytes is essential during treatment initiation 1

Pharmacological Management

First-Line Therapy

• ACE inhibitors should be initiated in all patients with heart failure with reduced ejection fraction (HFrEF) to reduce mortality and morbidity 1, 2

  • Start with low doses and titrate up gradually while monitoring blood pressure and renal function 1
  • For patients who cannot tolerate ACE inhibitors due to cough, angiotensin receptor blockers (ARBs) are recommended as an alternative 1, 2

• Beta-blockers should be initiated in all patients with HFrEF, regardless of age or comorbidities, using a "start-low, go-slow" approach 1, 2

  • Use only evidence-based beta-blockers: bisoprolol, metoprolol succinate, carvedilol, or nebivolol 1, 3
  • Initial dose of metoprolol succinate for heart failure is 25 mg once daily for NYHA Class II and 12.5 mg once daily for more severe heart failure 3
  • Dose should be doubled every two weeks to the highest tolerated level or up to 200 mg 3

• Diuretics should be administered to relieve congestion and fluid overload 1, 2

  • For new-onset heart failure or decompensated chronic heart failure without prior diuretic therapy, the initial recommended dose is 20-40 mg IV furosemide or equivalent 1
  • For patients on chronic diuretic therapy, the initial IV dose should be at least equivalent to their oral dose 1

Second-Line Therapy

• Mineralocorticoid receptor antagonists (spironolactone, eplerenone) are recommended for patients with advanced heart failure (NYHA III-IV) to improve survival 1, 2
• SGLT2 inhibitors have shown mortality benefit in HFrEF and should be considered as part of core therapy 2, 4
• Combination therapy with hydralazine and isosorbide dinitrate should be considered, particularly in African American patients 1, 2

Non-Pharmacological Management

• Regular aerobic exercise is recommended for all stable heart failure patients to improve functional capacity, symptoms, and reduce hospitalization risk 1
• Enrollment in a multidisciplinary care management program is recommended to reduce hospitalization and mortality 1, 2
• Sodium restriction may be necessary for patients with severe heart failure 1
• Fluid restriction should be considered in severe heart failure 1
• Alcohol intake should be limited 1

Common Pitfalls and Considerations

• Avoid NSAIDs or COX-2 inhibitors as they increase the risk of heart failure worsening and hospitalization 1
• Thiazolidinediones (glitazones) are not recommended as they increase the risk of heart failure worsening 1
• Inotropic agents should not be used unless the patient is symptomatically hypotensive or hypoperfused due to safety concerns 1
• If heart failure worsens during beta-blocker initiation, increase diuretic dose temporarily rather than discontinuing the beta-blocker 3
• For patients with cardiogenic shock, rapid transfer to a tertiary care center with 24/7 cardiac catheterization and ICU/CCU availability is essential 1

Advanced Therapies for Refractory Cases

• Cardiac resynchronization therapy (CRT) is recommended for symptomatic patients with HFrEF in sinus rhythm with QRS duration ≥150 msec and LBBB QRS morphology 1
• Implantable cardioverter-defibrillators (ICDs) should be considered for patients with HFrEF who remain at high risk for sudden cardiac death despite optimal medical therapy 1, 2
• For refractory cases, consider mechanical circulatory support, heart transplantation, or palliative care 2

Implementation Strategy

• Initiate all four pillars of GDMT (ACE inhibitors/ARBs, beta-blockers, MRAs, and SGLT2 inhibitors) as early as possible 2, 5, 4
• Schedule early follow-up visits within 7-14 days after hospital discharge 2
• Monitor renal function and electrolytes 1-2 weeks after each dose increment, at 3 months, and subsequently at 6-month intervals 1
• Continue evidence-based disease-modifying therapies even during worsening of chronic HFrEF, unless there is hemodynamic instability or contraindications 1