Initial Management for Patients with Heart Failure
The initial management for patients with heart failure should include ACE inhibitors and beta blockers for all patients with reduced ejection fraction, along with diuretics for those with fluid retention. 1
Classification and Assessment
- Heart failure is classified into four progressive stages (A-D), with corresponding New York Heart Association (NYHA) functional classifications (I-IV) 1
- Upon presentation, plasma natriuretic peptide level (BNP, NT-proBNP or MR-proANP) measurement is recommended in all patients with acute dyspnea and suspected acute heart failure to differentiate cardiac from non-cardiac causes 1
- Immediate ECG and echocardiography are recommended in all patients with suspected cardiogenic shock 1
Pharmacological Management
First-line Therapies
ACE inhibitors are recommended as first-line therapy in patients with reduced left ventricular ejection fraction (<40-45%) with or without symptoms 1
Beta blockers should be used in all patients with stable heart failure and reduced ejection fraction (NYHA class II-IV) who are on standard treatment, including diuretics and ACE inhibitors 1
- Beta blockers have been shown to improve survival, reduce hospitalizations, and improve symptoms 1
Diuretics (loop diuretics, thiazides) are essential for symptomatic treatment when fluid overload is present (pulmonary congestion or peripheral edema) 1
- In patients with new-onset acute heart failure or decompensated chronic heart failure not receiving oral diuretics, the initial recommended dose is 20-40 mg IV furosemide (or equivalent) 1
- For those on chronic diuretic therapy, the initial IV dose should be at least equivalent to the oral dose 1
- Regular monitoring of symptoms, urine output, renal function, and electrolytes is recommended during IV diuretic use 1
Additional Therapies Based on Clinical Status
Angiotensin receptor blockers (ARBs) may be used as an effective alternative in patients who develop cough or angioedema on an ACE inhibitor 1
Aldosterone antagonists are recommended in advanced heart failure (NYHA III-IV) in addition to ACE inhibition and diuretics to improve survival and reduce morbidity 1
Sacubitril/valsartan has demonstrated superiority to enalapril alone in reducing the risk of cardiovascular death or hospitalization for heart failure in patients with symptomatic chronic heart failure and reduced ejection fraction 2
Non-Pharmacological Management
Regular aerobic exercise is recommended for patients with heart failure to improve functional capacity, symptoms, and reduce the risk of heart failure hospitalization 1
Enrollment in a multidisciplinary care management program is recommended to reduce the risk of heart failure hospitalization and mortality 1
Sodium intake control is necessary for patients with severe heart failure 1
Avoid excessive fluid intake in severe heart failure 1
Treatments to Avoid
NSAIDs or COX-2 inhibitors are not recommended in patients with heart failure as they increase the risk of heart failure worsening and hospitalization 1
Thiazolidinediones (glitazones) should be avoided as they increase the risk of heart failure worsening 1
Inotropic agents are not recommended unless the patient is symptomatically hypotensive or hypoperfused due to safety concerns 1
Special Considerations
In case of worsening of chronic heart failure with reduced ejection fraction, every attempt should be made to continue evidence-based, disease-modifying therapies in the absence of hemodynamic instability or contraindications 1
Low blood pressure is often perceived as a barrier to GDMT initiation or maintenance, but if asymptomatic or minimally symptomatic, heart failure medications should be continued to realize their clinical benefits 1
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