What is the recommended treatment approach for congestive heart failure (CHF)?

Comprehensive Treatment Approach for Congestive Heart Failure

The recommended first-line treatment for congestive heart failure with reduced ejection fraction (HFrEF) includes a combination of ACE inhibitors/ARNIs, beta-blockers, mineralocorticoid receptor antagonists (MRAs), SGLT2 inhibitors, and diuretics as needed for congestion, which significantly reduces mortality and hospitalization. 1

First-Line Medications

ACE Inhibitors/ARNIs

• ACE inhibitors are recommended as first-line therapy in patients with reduced left ventricular systolic function, starting with a low dose and gradually titrating up to target maintenance doses 2, 3
• Sacubitril/valsartan (ARNI) is recommended as a replacement for ACE inhibitors in patients with HFrEF who remain symptomatic despite optimal treatment, providing superior reduction in cardiovascular death and heart failure hospitalization 3, 4
• When starting ACE inhibitors, review the need for and dose of diuretics, avoid excessive diuresis before treatment, and start with a low dose 2

Beta-Blockers

• Beta-blockers should be added for all stable patients with mild, moderate, and severe heart failure (NYHA class II-IV) who are already on standard treatment including diuretics and ACE inhibitors 3
• Beta-blockers should be initiated at low doses and gradually titrated to target doses as tolerated 1
• Beta-blockers are contraindicated in patients with severe bradycardia or high-degree heart block 1

Mineralocorticoid Receptor Antagonists (MRAs)

• MRAs (spironolactone or eplerenone) are recommended for patients who remain symptomatic despite treatment with an ACE inhibitor/ARNI and a beta-blocker 1, 3
• When using potassium-sparing diuretics, start with low doses and check serum potassium and creatinine after 5-7 days, then titrate accordingly 2

SGLT2 Inhibitors

• Dapagliflozin is strongly recommended for patients with HFrEF to reduce the risk of heart failure hospitalization and cardiovascular mortality, with benefits independent of diabetes status 1

Diuretics

• Diuretics are essential for symptomatic treatment when fluid overload is present (pulmonary congestion or peripheral edema) 2
• Diuretics should always be administered in combination with ACE inhibitors if possible 2
• For insufficient response, increase diuretic dose or combine loop diuretics and thiazides 2

Implementation Strategy

Medication Initiation and Titration

• Start with low doses of multiple medications simultaneously rather than waiting to reach target doses of one medication before starting another 1
• Gradually increase to target doses over 6-12 weeks 1
• Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, and subsequently at 6-month intervals 2, 3

Specific ACE Inhibitor Dosing

ACE Inhibitor	Starting dose (mg)	Target dose (mg)
Captopril	6.25 thrice daily	50-100 thrice daily
Enalapril	2.5 twice daily	10-20 twice daily
Lisinopril	2.5-5.0 once daily	30-35 once daily
Ramipril	2.5 once daily	5 twice daily or 10 once daily
Trandolapril	1.0 once daily	4 once daily
[2]

Device Therapies

• Implantable cardioverter defibrillators (ICDs) are recommended for patients with symptomatic HF (NYHA Class II-III), LVEF ≤35% despite ≥3 months of optimal medical therapy, and not within 40 days of myocardial infarction 1, 3
• Cardiac resynchronization therapy (CRT) is recommended for symptomatic heart failure patients in sinus rhythm with QRS duration ≥150 msec, LBBB QRS morphology, and LVEF ≤35% despite optimal medical therapy 1, 3

Non-Pharmacological Measures

• Provide patient education about heart failure, symptom recognition, and self-management 3
• Recommend daily physical activity in stable patients to prevent muscle deconditioning 3
• Control sodium intake when necessary, especially in patients with severe heart failure 3
• Avoid excessive fluid intake in severe heart failure 3

Common Pitfalls to Avoid

• Underutilization of guideline-directed medical therapy, inadequate dose titration, and inappropriate discontinuation of medications 1
• Avoid NSAIDs due to potential worsening of renal function and counteraction of beneficial effects of guideline-directed medical therapy 1
• Avoid diltiazem or verapamil in patients with HFrEF as they increase the risk of heart failure worsening 3
• Avoid the combination of an ACE inhibitor, ARB, and MRA due to increased risk of renal dysfunction and hyperkalemia 3

Management of Medication Side Effects

• For ACE inhibitor-induced cough, which rarely requires treatment discontinuation, consider substitution with an angiotensin receptor blocker if the cough is very troublesome 2
• For worsening renal function with ACE inhibitors, an increase in creatinine of up to 50% above baseline or to 3 mg/dl (266 mmol/l), whichever is greater, is acceptable 2
• If renal function deteriorates substantially with ACE inhibitors, consider stopping concomitant nephrotoxic drugs (e.g., NSAIDs) and reducing diuretic dose if no signs of congestion 2