What are the pillars of heart failure management?

Pillars of Heart Failure Management

The four pillars of heart failure management with reduced ejection fraction (HFrEF) consist of angiotensin receptor neprilysin inhibitors (ARNIs) or ACE inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and sodium-glucose co-transporter-2 (SGLT2) inhibitors, which together form the cornerstone of guideline-directed medical therapy. 1, 2

Pharmacological Management

First Pillar: Renin-Angiotensin System Inhibition

• ACE inhibitors are first-line therapy for patients with reduced left ventricular systolic function 3
• ARNIs (Angiotensin Receptor-Neprilysin Inhibitors) are preferred over ACE inhibitors in patients who can tolerate them 1
• These medications prevent cardiac remodeling and improve survival by blocking the harmful effects of the renin-angiotensin-aldosterone system 2

Second Pillar: Beta-Blockers

• Evidence-based beta-blockers improve survival and reduce hospitalizations in patients with HFrEF 3
• Should be initiated at low doses and gradually uptitrated to target doses as tolerated 2
• Contraindicated in patients with severe bronchospastic disease or symptomatic bradycardia 3

Third Pillar: Mineralocorticoid Receptor Antagonists

• MRAs (spironolactone, eplerenone) further block the renin-angiotensin-aldosterone system 1
• Particularly beneficial in patients with NYHA class II-IV symptoms 3
• Require monitoring of potassium levels and renal function 2

Fourth Pillar: SGLT2 Inhibitors

• Newest addition to the core HF therapy, showing significant reductions in cardiovascular mortality and HF hospitalizations 1, 2
• Benefits appear to be independent of glycemic status, making them appropriate for patients with and without diabetes 2
• Generally well-tolerated with minimal risk of hypoglycemia 2

Additional Pharmacological Therapies

Diuretics

• Essential for symptomatic treatment when fluid overload is present (pulmonary congestion or peripheral edema) 3
• Loop diuretics (e.g., furosemide) are first-line therapy for managing fluid retention 4
• Consider doubling the dose of loop diuretic up to equivalent of furosemide 500 mg if no initial response 4

Other Targeted Therapies

• Ivabradine may be considered for patients in sinus rhythm with heart rate ≥70 bpm despite maximum tolerated beta-blocker dose 2
• Hydralazine and isosorbide dinitrate combination is recommended for self-identified Black patients with NYHA class III-IV symptoms 2
• Vericiguat, a soluble guanylate cyclase stimulator, may be beneficial in patients with worsening HF, particularly older patients 5
• Intravenous iron supplementation for patients with iron deficiency 6

Non-Pharmacological Management

Patient Education and Self-Care

• Provide specific education about heart failure, symptom recognition, and self-monitoring 3
• Teach patients to monitor symptoms and weight fluctuations daily 3
• Encourage self-weighing and reporting weight gains of >2 kg in 3 days 3

Lifestyle Modifications

• Moderate sodium restriction (typically <2-3 g/day) 3
• Regular physical activity appropriate to functional capacity 3
• Smoking cessation and limited alcohol intake 7

Team-Based Care

• Multidisciplinary heart failure disease management programs for high-risk patients 3
• Early follow-up within 7 days of hospital discharge 3
• Comprehensive non-pharmacological intervention programs improve quality of life and reduce readmissions 7

Device Therapies

• Implantable cardioverter-defibrillators (ICDs) for primary or secondary prevention of sudden cardiac death in appropriate patients 6
• Cardiac resynchronization therapy (CRT) for patients with left bundle branch block and prolonged QRS duration 6
• Transcatheter mitral valve repair for selected patients with functional mitral regurgitation 6

Common Pitfalls to Avoid

• Inadequate diuresis in volume-overloaded patients 3
• Failure to uptitrate medications to target doses 3
• Neglecting patient education and self-care strategies 3
• Inadequate transitional care planning leading to early readmissions 3
• Excessive fluid administration in patients with a massively dilated right ventricle 4

Special Considerations

• For right heart failure, maintain oxygen saturation above 90% and consider pulmonary vasodilators like sildenafil in cases associated with pulmonary hypertension 4
• In right ventricular infarction, volume loading with normal saline may be beneficial unless there are signs of left heart volume overload 4
• 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

Despite advances in therapy, heart failure remains a progressive condition requiring ongoing monitoring and adjustment of treatment strategies to optimize outcomes and quality of life 8.