What are the initial management guidelines for patients with Congestive Heart Failure (CHF)?

Initial Management of Congestive Heart Failure

All patients with heart failure and reduced ejection fraction (HFrEF) should be started on the "fantastic four" medications—ACE inhibitors (or ARB/ARNI), beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors—as these are the only therapies proven to reduce mortality and hospitalization. 1, 2

Immediate Assessment and Stabilization

Volume Status Determination

• Assess for fluid overload by examining jugular venous distention, peripheral edema, pulmonary rales, and orthopnea 1
• Obtain chest radiograph (PA and lateral) to evaluate pulmonary congestion and cardiomegaly 1
• Measure weight and calculate body mass index at baseline for monitoring 1

Essential Diagnostic Workup

• Obtain 12-lead ECG to identify arrhythmias, prior MI, or conduction abnormalities 1
• Perform 2D echocardiography with Doppler to assess left ventricular ejection fraction (LVEF), chamber size, wall thickness, and valve function 1
• Order complete blood count, comprehensive metabolic panel (including electrolytes, BUN, creatinine, calcium, magnesium), fasting glucose, lipid profile, liver function tests, thyroid-stimulating hormone, and urinalysis 1
• Measure natriuretic peptides (BNP or NT-proBNP) to confirm diagnosis, though sensitivity is reduced in obesity and HFpEF 1

Pharmacological Management for HFrEF (LVEF ≤40%)

First-Line Therapy: The "Fantastic Four"

1. ACE Inhibitors (or ARB/ARNI)

• Start ACE inhibitors immediately in all HFrEF patients unless contraindicated (Class I, Level A) 1, 2
• Use ARBs if ACE inhibitor intolerant due to cough or angioedema (Class I, Level A) 1
• Switch to sacubitril/valsartan (ARNI) in patients who remain symptomatic despite optimal ACE inhibitor/ARB therapy to further reduce cardiovascular death and hospitalization (HR 0.80, p<0.0001) 1, 3
• Critical timing: Allow 36-hour washout period when switching from ACE inhibitor to ARNI to avoid angioedema 3

2. Beta-Blockers

• Use only the three proven beta-blockers: bisoprolol, carvedilol, or sustained-release metoprolol succinate (Class I, Level A) 1, 2
• Initiate once patient is clinically stable, not during acute decompensation 1
• Uptitrate slowly to target doses despite low blood pressure (80-100 mmHg systolic is acceptable if asymptomatic) 1

3. Mineralocorticoid Receptor Antagonists (MRAs)

• Start spironolactone or eplerenone in NYHA class II-IV patients with LVEF ≤35% (Class I, Level A) 1, 2
• Ensure creatinine ≤2.5 mg/dL (men) or ≤2.0 mg/dL (women) and potassium <5.0 mEq/L before initiating 1
• Monitor potassium and renal function closely as inappropriate use with hyperkalemia or renal insufficiency is potentially harmful (Class III: Harm) 1

4. SGLT2 Inhibitors

• Prescribe dapagliflozin or empagliflozin for all HFrEF patients to reduce hospitalization and death (Class I, Level A) 1
• This is the newest addition to guideline-directed medical therapy and should not be omitted 1

Diuretic Therapy for Congestion

Loop Diuretics

• Use loop diuretics (furosemide 20-40 mg, bumetanide 0.5-1 mg, or torsemide 10-20 mg) in all patients with fluid retention (Class I, Level C) 1, 2
• Torsemide has longest duration (12-16 hours) and may provide more consistent diuresis 1
• Titrate to relieve congestion, not to a specific dose—symptoms and weight guide dosing 1, 2
• Add thiazide diuretics (metolazone 2.5 mg or hydrochlorothiazide 25-100 mg) for sequential nephron blockade in diuretic-resistant cases 1

Additional Therapies

Digoxin

• Consider digoxin to improve symptoms and reduce hospitalizations in patients who remain symptomatic despite optimal therapy (Class IIa, Level B) 1
• Particularly useful in patients with atrial fibrillation for rate control 1

Hydralazine/Isosorbide Dinitrate

• Recommended for African American patients with NYHA class III-IV HFrEF already on optimal therapy (Class I, Level A) 1, 2
• Alternative for patients intolerant to ACE inhibitors and ARBs (Class IIa, Level B) 1

Medications to AVOID in HFrEF

These drugs worsen outcomes and should be discontinued:

• Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) increase mortality and heart failure (Class III: Harm) 1, 2
• NSAIDs cause sodium retention and blunt diuretic effects (Class III: Harm) 1, 2
• Thiazolidinediones (pioglitazone, rosiglitazone) increase heart failure events 2
• Most antiarrhythmic drugs except amiodarone and dofetilide have negative inotropic effects 2
• Triple neurohormonal blockade (ACE inhibitor + ARB + aldosterone antagonist) is potentially harmful 1

Uptitration Strategy

Systematic approach to reaching target doses:

• Alternate medication adjustments between ACE inhibitor/ARB and beta-blocker every 1-2 weeks 1
• Start low, go slow with small incremental increases, especially in elderly or those with chronic kidney disease 1
• Monitor vital signs including orthostatic blood pressure and heart rate before each uptitration 1
• Accept modest creatinine elevation (up to 30% increase) and systolic BP 80-100 mmHg if asymptomatic 1
• Continue GDMT during hospitalization unless hemodynamically unstable—discontinuation worsens outcomes 1

Anticoagulation for Atrial Fibrillation

• Prescribe chronic anticoagulation for all HF patients with atrial fibrillation and additional stroke risk factors (Class I, Level A) 1
• Consider anticoagulation even without additional risk factors in persistent/permanent AF (Class IIa, Level B) 1
• Do NOT anticoagulate HFrEF patients in sinus rhythm without prior thromboembolism (Class III: No Benefit) 1

Non-Pharmacological Management

• Provide structured patient education on self-care, daily weights, and symptom recognition (Class I, Level B) 1
• Recommend sodium restriction (reasonable for symptomatic patients, Class IIa, Level C) 1
• Prescribe exercise training or regular physical activity to improve functional status (Class I, Level A) 1
• Refer to cardiac rehabilitation in clinically stable patients to improve quality of life and mortality (Class IIa, Level B) 1
• Enroll in multidisciplinary HF management program to reduce hospitalization and improve survival (Class I, Level A) 1

Device Therapy Considerations

• ICD for primary prevention in patients with LVEF ≤35%, NYHA class II-III, at least 40 days post-MI, on optimal medical therapy, and life expectancy >1 year (Class I, Level A) 1
• CRT for patients with LVEF ≤35%, sinus rhythm, QRS ≥150 ms with LBBB morphology, and symptomatic despite GDMT (Class I, Level A) 1

Common Pitfalls to Avoid

• Do not delay beta-blocker initiation waiting for "perfect" blood pressure—most patients tolerate them despite systolic BP 80-100 mmHg 1
• Do not discontinue GDMT for mild creatinine elevation or asymptomatic hypotension during hospitalization 1
• Do not use all three neurohormonal antagonists (ACE inhibitor + ARB + MRA) together—this increases hyperkalemia risk 1
• Do not prescribe statins solely for heart failure—they provide no benefit when HF is the only indication (Class III: No Benefit) 1