What are the initial treatment guidelines for new heart failure?

Initial Treatment Guidelines for New Heart Failure

ACE inhibitors should be used as first-line therapy in patients with reduced left ventricular systolic function, in combination with diuretics when fluid overload is present. 1, 2

First-Line Medications

• ACE inhibitors are the cornerstone of heart failure treatment for patients with reduced left ventricular ejection fraction to reduce mortality and hospitalizations 1, 2
• Diuretics (loop diuretics or thiazides) are essential for symptomatic treatment when fluid overload is present, manifesting as pulmonary congestion or peripheral edema 1
• Beta-blockers are recommended for all stable patients with mild, moderate, and severe heart failure with reduced ejection fraction (NYHA class II-IV) who are already on standard treatment including diuretics and ACE inhibitors 1, 2

Initiating ACE Inhibitors

• Review the need for and dose of diuretics and vasodilators before starting 1
• Avoid excessive diuresis before treatment - reduce or withhold diuretics for 24 hours if possible 1
• Start with a low dose and gradually titrate up to recommended maintenance dosages 1
• Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, and subsequently at 6-month intervals 1
• Avoid potassium-sparing diuretics during initiation of ACE inhibitor therapy 1
• Avoid NSAIDs as they may worsen renal function 1

Diuretic Management

• Loop diuretics or thiazides should be administered in addition to an ACE inhibitor 1
• For patients with GFR < 30 ml/min, avoid thiazides except when prescribed synergistically with loop diuretics 1
• If response is insufficient, increase diuretic dose or combine loop diuretics with thiazides 1
• For persistent fluid retention, administer loop diuretics twice daily 1
• Potassium-sparing diuretics should only be used if hypokalemia persists after initiation of ACE inhibitors and diuretics 1, 2

Adding Beta-Blockers

• Patients should be on background therapy with ACE inhibition before starting beta-blockers 1
• The patient should be in relatively stable condition without need for intravenous inotropic therapy and without signs of marked fluid retention 1
• Start with a very low dose and titrate up slowly (every 1-2 weeks) if the preceding dose was well tolerated 1
• Monitor for worsening heart failure symptoms, fluid retention, hypotension, and bradycardia during titration 1

Second-Line and Add-On Medications

• Aldosterone receptor antagonists (spironolactone) are recommended in advanced heart failure (NYHA III-IV) in addition to ACE inhibition and diuretics 1, 3
• Angiotensin II receptor blockers (ARBs) can be used in patients who do not tolerate ACE inhibitors 1, 2
• Cardiac glycosides (digoxin) are indicated in atrial fibrillation with heart failure to slow ventricular rate 1, 2
• Digoxin can also be used in sinus rhythm to improve clinical status in patients with persistent symptoms despite ACE inhibitor and diuretic treatment 1

Common Pitfalls and Caveats

• Failure to initiate ACE inhibitors as first-line therapy in eligible patients 4, 5
• Inadequate dosing of medications - many patients receive less than target doses of GDMT 6
• Not monitoring renal function and electrolytes after initiation or dose changes of ACE inhibitors, ARBs, or aldosterone antagonists 1, 2
• Using potassium-sparing diuretics during ACE inhibitor initiation, increasing risk of hyperkalemia 1
• Underutilization of beta-blockers or using non-evidence-based beta-blockers instead of heart failure-specific ones (metoprolol succinate, carvedilol, bisoprolol) 5
• Failure to refer patients to heart failure specialists, which is associated with better GDMT initiation 5