What are the medications for congestive heart failure (CHF)?

Core Medications for Congestive Heart Failure

The four foundational medication classes for CHF are ACE inhibitors (or ARBs), beta-blockers, mineralocorticoid receptor antagonists (spironolactone), and diuretics, with these agents proven to reduce mortality and hospitalizations when used together. 1

First-Line Therapy: ACE Inhibitors + Beta-Blockers

Both ACE inhibitors and beta-blockers should be initiated as first-line treatment in all patients with NYHA class I-IV CHF unless contraindicated. 1

ACE Inhibitors

• Proven to increase survival, reduce hospital admissions, and improve NYHA class and quality of life across all grades of symptomatic CHF. 1
• Higher doses reduce death or hospitalization more than lower doses, so titrate to target doses used in clinical trials. 1

Specific ACE Inhibitors and Dosing: 1

• Enalapril: Start 2.5 mg twice daily → Target 10-20 mg twice daily
• Lisinopril: Start 2.5-5.0 mg once daily → Target 30-35 mg once daily
• Ramipril: Start 2.5 mg once daily → Target 5 mg twice daily or 10 mg once daily
• Captopril: Start 6.25 mg three times daily → Target 50-100 mg three times daily
• Trandolapril: Start 1.0 mg once daily → Target 4 mg once daily

Titration Strategy: 1

• Start with low dose
• Double dose at minimum 2-week intervals
• Monitor blood pressure, urea, creatinine, and potassium before each increase
• Remember: some ACE inhibitor is better than no ACE inhibitor if target dose not tolerated

Beta-Blockers

Only three beta-blockers have proven mortality reduction in heart failure—this is NOT a class effect. 1

Evidence-Based Beta-Blockers: 1

• Bisoprolol: Start 1.25 mg once daily → Target 10 mg once daily
• Carvedilol: Start 3.125 mg twice daily → Target 25-50 mg twice daily
• Metoprolol CR/XL: Start 12.5-25 mg once daily → Target 200 mg once daily

Initiate beta-blockers in stable patients only—NOT during acute decompensation or within 4 weeks of hospitalization for worsening CHF. 1

Third Medication: Mineralocorticoid Receptor Antagonist

Spironolactone prevents 57 deaths per 1000 patient-years of treatment—the highest mortality benefit among CHF medications. 1

• Add spironolactone to ACE inhibitor + beta-blocker therapy in patients with moderate to severe CHF (NYHA class III-IV). 1
• Monitor potassium closely—seek specialist advice if K+ >5.0 mmol/L before initiation or rises to >6.0 mmol/L during treatment. 1

Fourth Medication: Diuretics

Diuretics are essential for symptomatic management of congestion but do not improve mortality. 2, 3

• Use loop diuretics for patients with signs of fluid overload (peripheral edema, elevated JVP, pulmonary congestion). 2, 3
• Optimize diuretic dose to achieve euvolemia before or during ACE inhibitor/beta-blocker titration. 1
• Consider combination diuretics (loop + thiazide or spironolactone) for diuretic resistance. 4

Newer Option: Sacubitril/Valsartan (ARNI)

Sacubitril/valsartan (combining neprilysin inhibitor + ARB) is superior to enalapril alone, reducing cardiovascular death or HF hospitalization by 20%. 5

• Consider replacing ACE inhibitor with sacubitril/valsartan in patients with NYHA class II-IV CHF and LVEF ≤40% who remain symptomatic on ACE inhibitor + beta-blocker. 5
• Dosing: Start 49/51 mg twice daily → Target 97/103 mg twice daily 5
• Requires 36-hour washout period after stopping ACE inhibitor to avoid angioedema. 5

Critical Cautions

Seek specialist advice before initiating ACE inhibitors if: 1

• Creatinine >2.5 mg/dL (>221 μmol/L)
• Potassium >5.0 mmol/L
• Systolic BP <90 mmHg with symptoms

Do NOT initiate beta-blockers if: 1

• NYHA class IV with severe decompensation
• Current or recent (within 4 weeks) hospitalization for worsening CHF
• Heart rate <60 bpm or heart block
• Persistent signs of congestion (elevated JVP, ascites, marked peripheral edema)

Monitoring During Titration

For ACE Inhibitors: 1

• Accept creatinine increases up to 50% above baseline or to 3 mg/dL (266 μmol/L), whichever is greater
• Accept potassium up to 5.5 mmol/L
• Halve ACE inhibitor dose if creatinine doubles or K+ reaches 6.0 mmol/L
• Asymptomatic hypotension requires no action

For Beta-Blockers: 1

• Check blood chemistry 1-2 weeks after initiation and after final dose titration
• If worsening congestion develops, double diuretic dose first before reducing beta-blocker
• Temporary symptomatic deterioration occurs in 20-30% during titration—manage with medication adjustment, not discontinuation
• Never stop beta-blockers abruptly unless absolutely necessary

Additional Considerations

Digoxin reduces hospitalizations by 40 per 1000 patient-years but does not improve mortality—reserve for patients with persistent symptoms despite optimal therapy or those with atrial fibrillation. 1

Avoid calcium channel blockers (especially non-dihydropyridines like verapamil and diltiazem) unless absolutely essential for angina or hypertension, as they worsen outcomes in CHF. 1, 3