What is the initial medication regimen for a new diagnosis of congestive heart failure (CHF)?

Initial Medication Regimen for New Diagnosis of Congestive Heart Failure (CHF)

The initial medication regimen for newly diagnosed congestive heart failure with reduced ejection fraction should include an ACE inhibitor and a beta-blocker as first-line therapy, with diuretics added for symptomatic relief of congestion. 1, 2

First-Line Medications

ACE Inhibitors

• ACE inhibitors are recommended as first-line therapy for all patients with heart failure with reduced ejection fraction (HFrEF) to reduce mortality and hospitalization 1, 2
• Start with a low dose and gradually titrate up to target doses shown to be effective in clinical trials 1
• When initiating ACE inhibitors, review the need for and dose of diuretics, avoid excessive diuresis, and monitor blood pressure, renal function, and electrolytes 1
• Common pitfalls: Avoid potassium-sparing diuretics during initiation of ACE inhibitor therapy and avoid NSAIDs as they may worsen renal function 1, 2

Beta-Blockers

• Beta-blockers are recommended for all stable patients with mild, moderate, and severe heart failure with reduced ejection fraction (NYHA class II-IV) 1
• Beta-blockers should be initiated once the patient is stabilized on ACE inhibitors and diuretics 2
• Beta-blockers have been shown to reduce mortality and hospitalization in HFrEF patients 1
• Start with low doses and gradually titrate up as tolerated 2

Diuretics

• Diuretics are essential for symptomatic relief when fluid overload is present 1, 2
• Loop diuretics or thiazides are first-line options for initial diuretic treatment 1
• Diuretics should always be administered in combination with ACE inhibitors when possible 1, 2
• If GFR < 30 ml/min, avoid thiazides except when prescribed synergistically with loop diuretics 1
• For insufficient response, increase the dose of diuretic or combine loop diuretics and thiazides 1

Second-Line and Add-On Medications

Mineralocorticoid Receptor Antagonists (MRAs)

• MRAs (such as spironolactone) are recommended for patients who remain symptomatic despite treatment with ACE inhibitors and beta-blockers 1, 2
• MRAs have been shown to improve survival and reduce hospitalization in HFrEF patients 1
• When using MRAs, monitor potassium and renal function closely 2

Angiotensin Receptor Blockers (ARBs)

• ARBs are an alternative for patients who cannot tolerate ACE inhibitors due to side effects like cough 1, 2
• ARBs have fewer side effects, notably cough, compared to ACE inhibitors 1
• However, it is unclear whether ARBs are as effective as ACE inhibitors for mortality reduction 1

Sacubitril/Valsartan

• Sacubitril/valsartan is recommended as a replacement for ACE inhibitors in patients who remain symptomatic despite optimal treatment with an ACE inhibitor, a beta-blocker, and an MRA 1, 2
• The PARADIGM-HF trial demonstrated that sacubitril/valsartan was superior to enalapril in reducing the risk of cardiovascular death or hospitalization for heart failure 3
• Sacubitril/valsartan also improved overall survival compared to enalapril 3

Cardiac Glycosides (Digoxin)

• Digoxin is indicated for patients with atrial fibrillation and heart failure to slow ventricular rate 1
• In sinus rhythm, digoxin is recommended for patients who remain symptomatic despite ACE inhibitors and diuretics 1
• A combination of digoxin and beta-blockade appears superior to either agent alone 1

Stepwise Approach to Medication Initiation

1. Start with an ACE inhibitor and diuretics for symptomatic relief of congestion 1, 2, 4
2. Add a beta-blocker once the patient is stabilized 2, 4
3. Add an MRA for patients who remain symptomatic despite optimal therapy with ACE inhibitors and beta-blockers 1, 2
4. Consider replacing the ACE inhibitor with sacubitril/valsartan in patients who remain symptomatic despite optimal treatment 1, 3

Common Pitfalls and Caveats

• Avoid initiating potassium-sparing diuretics during ACE inhibitor therapy initiation 1
• Avoid NSAIDs in patients on ACE inhibitors as they may worsen renal function 1
• Diltiazem and verapamil are not recommended in patients with HFrEF as they increase the risk of heart failure worsening 1, 2
• The addition of an ARB to the combination of an ACE inhibitor and an MRA is not recommended due to increased risk of renal dysfunction and hyperkalemia 1
• Careful monitoring of renal function and electrolytes is essential when using ACE inhibitors, ARBs, and MRAs 2
• Heart failure clinic referral is associated with higher rates of guideline-directed medical therapy initiation across all medication classes 5