Initial Treatment for Suspected Congestive Heart Failure (CHF)
The initial treatment for a patient with suspected congestive heart failure should include diuretics to relieve congestion symptoms, an ACE inhibitor, and a beta-blocker, with careful attention to proper dosing and monitoring of renal function and electrolytes. 1
Diagnostic Confirmation
Before initiating treatment, confirm the diagnosis:
- Perform transthoracic echocardiography (TTE) to assess myocardial structure and function and establish a diagnosis of either HFrEF, HFmrEF, or HFpEF 1
- Measure left ventricular ejection fraction (LVEF) to identify patients suitable for evidence-based pharmacological and device treatments 1
- Consider measuring plasma natriuretic peptide levels (BNP, NT-proBNP) in patients with acute dyspnea to help differentiate cardiac from non-cardiac causes 1
Initial Pharmacological Treatment
Diuretics
- Diuretics are recommended as first-line therapy for patients with signs and/or symptoms of congestion to improve symptoms and exercise capacity 1
- Initial diuretic options:
- Loop diuretics (e.g., furosemide 20-40 mg once or twice daily) or thiazides 1
- For patients with new-onset CHF not on oral diuretics, start with 20-40 mg IV furosemide (or equivalent) 1
- For patients already on chronic diuretic therapy, initial IV dose should be at least equivalent to oral dose 1
- Avoid thiazides if GFR < 30 ml/min except when prescribed synergistically with loop diuretics 1
ACE Inhibitors
- ACE inhibitors are recommended for all symptomatic patients with HFrEF to reduce the risk of HF hospitalization and death 1
- When starting an ACE inhibitor:
- Review the need for and dose of diuretics and vasodilators
- Avoid excessive diuresis before treatment; reduce or withhold diuretics for 24 hours if possible
- Start with a low dose and titrate up to recommended maintenance dosages
- Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment 1
- Avoid potassium-sparing diuretics during initiation of therapy 1
Beta-Blockers
- Beta-blockers are recommended for patients with stable, symptomatic HFrEF to reduce the risk of HF hospitalization and death 1
- Beta-blockers should be initiated at low doses and gradually titrated up to target doses as tolerated 1
- Use one of the three beta-blockers proven to reduce mortality: bisoprolol, carvedilol, or sustained-release metoprolol succinate 1
Special Considerations
For Advanced Heart Failure (NYHA III-IV)
- Consider adding an aldosterone receptor antagonist (e.g., spironolactone) to improve survival and reduce morbidity 1
- For patients who remain symptomatic despite optimal treatment with an ACE inhibitor and beta-blocker, consider sacubitril/valsartan as a replacement for ACE inhibitor 1, 2
For Patients Unable to Tolerate ACE Inhibitors
- Angiotensin receptor blockers (ARBs) are recommended as an alternative to reduce morbidity and mortality 1
Monitoring and Follow-up
- Regularly monitor symptoms, urine output, renal function, and electrolytes during use of diuretics 1
- Check blood pressure, renal function, and electrolytes 1-2 weeks after each medication dose increment, at 3 months, and subsequently at 6-month intervals 1
- Adjust diuretic doses according to the patient's symptoms and clinical status 1
Non-Pharmacological Recommendations
- Provide patient education about heart failure, symptom recognition, and self-management 1
- Encourage regular aerobic exercise in stable patients to improve functional capacity and symptoms 1
- Consider sodium restriction for patients with symptomatic heart failure to reduce congestive symptoms 1
- Enroll patients in a multidisciplinary care management program to reduce the risk of HF hospitalization and mortality 1