What is the recommended treatment regimen for heart failure?

Heart Failure Treatment Regimen

The recommended treatment regimen for heart failure should include ACE inhibitors as first-line therapy in patients with reduced left ventricular systolic function, combined with diuretics for symptomatic relief, and beta-blockers for all stable patients, with mineralocorticoid receptor antagonists added for patients who remain symptomatic despite optimal therapy. 1, 2

First-Line Pharmacological Therapy

• ACE inhibitors should be started with a low dose and gradually titrated up to target maintenance doses shown to be effective in clinical trials 3
• Diuretics (loop diuretics or thiazides) are essential for symptomatic treatment when fluid overload is present and should always be administered in addition to an ACE inhibitor 3
• For patients with reduced renal function (GFR < 30 ml/min), avoid thiazides except when used synergistically with loop diuretics 3
• Beta-blockers are recommended for all patients with stable mild, moderate, and severe heart failure with reduced LV ejection fraction (NYHA class II-IV) who are already on standard treatment including diuretics and ACE inhibitors 3

Stepwise Treatment Approach

1. Initial therapy: Start with ACE inhibitor and diuretic therapy

   • Review the need for and dose of diuretics before starting ACE inhibitor 3
   • Avoid excessive diuresis before treatment; consider reducing or withholding diuretics for 24 hours 3
   • Start with a low dose of ACE inhibitor and build up to recommended maintenance dosages 3
   • Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment 3, 1

2. Add beta-blocker once patient is stable on ACE inhibitor and diuretic therapy 3, 2

   • Beta-blockers reduce hospitalizations, improve functional class, and prevent worsening of heart failure 2
   • Titrate dose gradually to target doses shown to be effective in clinical trials 1

3. Add mineralocorticoid receptor antagonist (MRA) for patients with advanced heart failure (NYHA III-IV) who remain symptomatic despite ACE inhibition and diuretics 3

   • Spironolactone is recommended to improve survival and reduce morbidity 3
   • Monitor serum potassium and creatinine carefully when initiating therapy and during dose adjustments 2

4. Consider ARBs in patients who do not tolerate ACE inhibitors for symptomatic treatment 3

   • Side effects, notably cough, are significantly less than with ACE inhibitors 3
   • In combination with ACE inhibition, ARBs may improve heart failure symptoms and reduce hospitalizations 3

5. Consider sacubitril/valsartan for ambulatory patients with HFrEF who remain symptomatic despite optimal treatment with an ACE inhibitor, a beta-blocker, and an MRA 1, 4

   • PARADIGM-HF demonstrated that sacubitril/valsartan was superior to enalapril in reducing the risk of cardiovascular death or hospitalization for heart failure 4

6. Consider digoxin for patients with atrial fibrillation and heart failure to slow ventricular rate 3

   • In sinus rhythm, digoxin is recommended for patients with persisting symptoms despite ACE inhibitor and diuretic treatment 3
   • The usual daily dose is 0.25-0.375 mg if serum creatinine is normal (0.125-0.25 mg in elderly) 3

Monitoring and Dose Adjustment

• When starting ACE inhibitors:

  • Check blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, and subsequently at 6-month intervals 3, 1
  • If renal function deteriorates substantially, stop treatment 3
  • Avoid potassium-sparing diuretics during initiation of therapy 3
  • Avoid NSAIDs 3

• For diuretic therapy:

  • If response is insufficient, increase dose of diuretic or combine loop diuretics and thiazides 3
  • With persistent fluid retention, administer loop diuretics twice daily 3
  • In severe chronic heart failure, consider adding metolazone with frequent measurement of creatinine and electrolytes 3

Common Pitfalls and Special Considerations

• Avoid excessive diuresis before initiating ACE inhibitor therapy, as this can lead to hypotension 3
• Avoid the combination of an ACE inhibitor, ARB, and MRA due to increased risk of renal dysfunction and hyperkalemia 1
• When using potassium-sparing diuretics, start with low-dose administration and check serum potassium and creatinine after 5-7 days 3
• Avoid diltiazem or verapamil in patients with HFrEF as they increase the risk of heart failure worsening 1
• For patients with heart failure and atrial fibrillation, a combination of digoxin and beta-blockade appears superior to either agent alone 3

Non-Pharmacological Measures

• Control sodium intake when necessary, especially in patients with severe heart failure 3, 2
• Avoid excessive fluid intake in severe heart failure 3, 2
• Recommend daily physical activity in stable patients to prevent muscle deconditioning 1, 2
• Provide patient education about heart failure, symptom recognition, and self-management 1, 2