What is the initial management of Congestive Heart Failure (CHF)?

Initial Management of Congestive Heart Failure

Start ACE inhibitors immediately in all patients with reduced ejection fraction (HFrEF, LVEF ≤40%), beginning with low doses and titrating upward, while simultaneously administering diuretics for fluid overload and adding beta-blockers once the patient is stabilized. 1, 2

Immediate Assessment and Classification

Clinical Evaluation:

• Assess volume status by examining jugular venous pressure, pulmonary crackles, peripheral edema, and orthostatic blood pressure changes 3
• Measure weight, height, and calculate body mass index 3
• Evaluate ability to perform activities of daily living and NYHA functional class (I-IV) 3, 1
• Obtain detailed history of alcohol, illicit drugs, chemotherapy exposure, and alternative therapies 3

Essential Diagnostic Testing:

• 12-lead ECG and chest X-ray (PA and lateral) in all patients 3
• Two-dimensional echocardiography with Doppler to assess LVEF, left ventricular size, wall thickness, and valve function 3
• Laboratory panel: complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), BUN, creatinine, fasting glucose, glycohemoglobin, lipid profile, liver function tests, and thyroid-stimulating hormone 3

Classify by ejection fraction:

• HFrEF: LVEF ≤40% 1
• HFpEF: LVEF ≥50% 1

Pharmacological Management for HFrEF

ACE Inhibitors (First-Line Therapy):

• Start immediately in all HFrEF patients unless contraindicated 3, 1, 2
• Specific dosing regimens: 2, 4
  • Lisinopril: Start 2.5-5 mg daily, target 20-35 mg daily
  • Enalapril: Start 2.5 mg twice daily, target 10-20 mg twice daily
  • Ramipril: Start 2.5 mg daily, target 5 mg twice daily
  • Captopril: Start 6.25 mg three times daily, target 50 mg three times daily
• Titrate to target doses proven in clinical trials, not just symptomatic improvement 2
• Monitor renal function and electrolytes 1-2 weeks after each dose change, then at 3-6 month intervals 2

Diuretics (For Symptomatic Relief):

• Administer loop diuretics (furosemide preferred) for all patients with fluid overload 1, 2
• Provide rapid symptomatic relief through immediate venodilation and subsequent fluid removal 3
• Monitor urine output, renal function, and electrolytes regularly 3, 2
• For insufficient response, combine loop diuretic with thiazide or metolazone 2
• Adjust diuretic dose to minimize hypovolemia which may contribute to hypotension 4

Beta-Blockers (Add After Stabilization):

• Initiate only after patient is stable on ACE inhibitors and diuretics 1, 2
• Use only proven agents: bisoprolol, carvedilol, or metoprolol CR/XL 2
• Start at low doses and titrate slowly 2
• Indicated for NYHA class II-IV patients 1, 2

Management for HFpEF

Treatment focuses on comorbidities and symptom relief:

• Treat hypertension, diabetes, obesity, atrial fibrillation, coronary artery disease, chronic kidney disease, and obstructive sleep apnea 1
• Use diuretics judiciously to reduce congestion and improve symptoms 1
• Consider SGLT2 inhibitors (dapagliflozin, empagliflozin) which have shown benefit 1

Special Populations

Renal Impairment:

• Creatinine clearance >30 mL/min: No dose adjustment needed 4
• Creatinine clearance 10-30 mL/min: Reduce initial lisinopril dose to 5 mg for hypertension, 2.5 mg for heart failure 4
• Hemodialysis or creatinine clearance <10 mL/min: Start lisinopril at 2.5 mg once daily 4
• Beta-blockers improve outcomes in all CKD stages, including dialysis patients 5

Acute Myocardial Infarction:

• In hemodynamically stable patients within 24 hours of MI onset: Give lisinopril 5 mg orally, then 5 mg after 24 hours, 10 mg after 48 hours, then 10 mg daily for at least 6 weeks 4
• For low systolic BP (≤120 mmHg and >100 mmHg): Start with 2.5 mg 4
• If systolic BP ≤100 mmHg: Maintain 5 mg daily with temporary reductions to 2.5 mg if needed 4
• Withdraw if prolonged hypotension (systolic BP <90 mmHg for >1 hour) 4

Patients on Diuretics:

• Reduce initial ACE inhibitor dose to 5 mg once daily in adults already taking diuretics 4
• Start with 2.5 mg in heart failure patients with hyponatremia (serum sodium <130 mEq/L) 4

Non-Pharmacological Management

Patient Education:

• Teach symptom recognition, importance of daily self-weighing, and medication adherence 1

Dietary Modifications:

• Implement sodium restriction for symptomatic patients to reduce congestion 1

Physical Activity:

• Encourage regular exercise in stable patients to prevent muscle deconditioning 1

Critical Pitfalls to Avoid

Medication Errors:

• Never discontinue guideline-directed medical therapy during hospitalization unless absolutely necessary; reinitiate as soon as possible if stopped 2
• Avoid alpha-adrenergic blockers and calcium antagonists (especially diltiazem and verapamil) as there is no evidence supporting their use 2
• Avoid NSAIDs and COX-2 inhibitors as they increase risk of heart failure worsening and hospitalization 2

Monitoring Failures:

• Do not titrate ACE inhibitors based solely on symptoms; use target doses from clinical trials 2
• Hypotension after initial ACE inhibitor dose does not preclude careful subsequent titration after managing the hypotension 4

Follow-Up Protocol

Early Post-Discharge:

• Primary care visit within 1 week of hospital discharge 1, 2
• Cardiology team visit within 2 weeks 1, 2
• Consider telephone follow-up within 3 days of discharge 2

Ongoing Monitoring:

• Check heart rate, blood pressure, renal function, and electrolytes 1-2 weeks after each medication dose change 1, 2
• Assess fluid status regularly through daily weights, jugular venous pressure, and extent of pulmonary and peripheral edema 1
• All patients should be followed by a multidisciplinary heart failure service 2