Congestive Heart Failure Treatment
The treatment of congestive heart failure requires a combination of ACE inhibitors as first-line therapy for reduced left ventricular systolic function, beta-blockers for all stable patients, diuretics for fluid overload, and mineralocorticoid receptor antagonists for patients who remain symptomatic despite standard therapy. 1, 2
Initial Assessment and Classification
- Determine heart failure type: heart failure with reduced ejection fraction (HFrEF, EF ≤40%) or heart failure with preserved ejection fraction (HFpEF, EF ≥50%) 1
- Assess severity using New York Heart Association (NYHA) functional classification 1
- Identify etiology and precipitating factors of heart failure 3, 1
- Evaluate for concomitant diseases relevant to heart failure management 3, 1
Pharmacological Management
First-Line Medications
ACE inhibitors are recommended as first-line therapy for patients with reduced LV systolic function 3, 2
- Start with low dose and gradually titrate up to target maintenance doses
- Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment 2
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 2
Diuretics are essential for symptomatic treatment when fluid overload is present 3, 2
Additional Medications
Mineralocorticoid receptor antagonists (MRAs) like spironolactone are recommended for patients who remain symptomatic despite treatment with an ACE inhibitor and a beta-blocker 2
- Spironolactone retards fibrous tissue development and improves prognosis 6
Sacubitril/valsartan is recommended as a replacement for an ACE inhibitor in ambulatory patients with HFrEF who remain symptomatic despite optimal treatment 2
For patients who cannot take an ACE inhibitor, the combination of hydralazine and nitrates may offer prognostic benefit 6, 7
Device Therapy
- Implantable cardioverter defibrillators (ICDs) are recommended for patients who have recovered from ventricular arrhythmia causing hemodynamic instability 2
- ICDs are also recommended for patients with symptomatic HF (NYHA Class II-III) and LVEF ≤35% despite optimal medical therapy for at least 3 months 2
- 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% 2
Management of Arrhythmias
- For ventricular arrhythmias, antiarrhythmic agents are only justified in patients with severe, symptomatic, sustained ventricular tachycardias, with amiodarone as the preferred agent 3
- For atrial fibrillation, rate control is mandatory with beta-blockers, digitalis glycosides, or a combination 3, 7
Non-Pharmacological Management
- Provide specific education about heart failure, symptoms recognition, and self-monitoring 1, 2
- Teach patients to monitor symptoms and weight fluctuations daily 1
- Encourage self-weighing and reporting weight gains of >2 kg in 3 days 1
- Daily physical activity in stable patients to prevent muscle deconditioning 3, 8
- Control sodium intake when necessary, especially in patients with severe heart failure 3, 8
- Avoid excessive fluid intake in severe heart failure 3
- Smoking cessation and limited alcohol intake 1, 8
Transitional and Team-Based Care
- Refer high-risk heart failure patients to multidisciplinary heart failure disease management programs 1
- Schedule early follow-up, generally within 7 days of hospital discharge 1
Common Pitfalls to Avoid
- Inadequate diuresis in volume-overloaded patients 1
- Failure to uptitrate medications to target doses 1
- Neglecting patient education and self-care strategies 1
- Inadequate transitional care planning leading to early readmissions 1
- Avoiding diltiazem or verapamil in patients with HFrEF as they increase the risk of heart failure worsening 2
- Avoiding the combination of an ACE inhibitor, ARB, and MRA due to increased risk of renal dysfunction and hyperkalemia 2