What are the management strategies for Congestive Heart Failure (CHF)?

Comprehensive Management of Congestive Heart Failure

Staging and Risk Stratification

All patients with heart failure should be classified using the ACC/AHA staging system (A through D) to guide treatment intensity and prognosis. 1, 2

• Stage A (at risk, no structural disease): Focus on aggressive control of hypertension with target BP <130/80 mmHg if cardiovascular risk >10%, treat hyperlipidemia, and consider ACE inhibitors or ARBs in appropriate patients 1, 2
• Stage B (structural disease, no symptoms): Initiate ACE inhibitors or ARBs and beta-blockers in all patients with reduced ejection fraction, particularly post-myocardial infarction 1, 2
• Stage C (structural disease with current/prior symptoms): Implement full guideline-directed medical therapy (GDMT) with the four pillars: ACE inhibitor/ARB/ARNI, beta-blocker, mineralocorticoid receptor antagonist, and SGLT2 inhibitor 1, 2
• Stage D (refractory symptoms despite maximal therapy): Evaluate for mechanical circulatory support, cardiac transplantation, or palliative care 1, 2

Classification by Ejection Fraction

Determine left ventricular ejection fraction (LVEF) by transthoracic echocardiography immediately, as this dictates the entire treatment algorithm. 1

• HFrEF (LVEF ≤40%): Evidence-based therapies proven to reduce mortality exist only for this phenotype 1
• HFpEF (LVEF ≥50%): Manage comorbidities aggressively, use diuretics for congestion, and initiate SGLT2 inhibitors 1, 3
• HFmrEF (LVEF 41-49%): Treat similarly to HFrEF with GDMT 1

Core Pharmacological Therapy for HFrEF

The Four Pillars (initiate all four simultaneously or in rapid sequence)

1. ACE Inhibitor/ARB/ARNI (First Pillar)

Start enalapril 2.5-5 mg twice daily and uptitrate to target dose of 10-20 mg twice daily over 2-4 weeks. 1, 4

• ACE inhibitors reduce mortality and hospitalization in all symptomatic patients with LVEF ≤40% 1, 2
• If ACE inhibitor causes cough or angioedema, switch to ARB (not ARNI if angioedema occurred) 1
• If hypotension or renal insufficiency prevents ACE inhibitor use, substitute hydralazine 37.5-75 mg three times daily plus isosorbide dinitrate 20-40 mg three times daily 1
• Monitor creatinine and potassium within 1-2 weeks after initiation and after each dose increase 2
• Accept creatinine increase up to 30% above baseline and potassium up to 5.5 mEq/L unless symptomatic 1

2. Beta-Blocker (Second Pillar)

Start metoprolol succinate 12.5-25 mg once daily (12.5 mg if NYHA Class III-IV) and double the dose every 2 weeks to target of 200 mg daily. 1, 5

• Beta-blockers reduce mortality and hospitalization when added to ACE inhibitors 1, 2
• Initiate only after patient is euvolemic and off IV diuretics, vasodilators, and inotropes 3, 5
• Evidence-based agents: metoprolol succinate, carvedilol, or bisoprolol 1
• If transient worsening occurs, increase diuretics and temporarily reduce (not discontinue) beta-blocker dose 5
• If symptomatic bradycardia develops, reduce dose 5

3. Mineralocorticoid Receptor Antagonist (Third Pillar)

Add spironolactone 12.5-25 mg once daily (maximum 50 mg) in patients with NYHA Class II-IV symptoms despite ACE inhibitor and beta-blocker. 1

• Reduces mortality in patients with recent or current Class IV symptoms 1
• Requires preserved renal function (creatinine ≤2.5 mg/dL in men, ≤2.0 mg/dL in women) and normal potassium (<5.0 mEq/L) 1
• Monitor potassium and creatinine within 3 days, then at 1 week, then monthly for 3 months, then quarterly 1
• Discontinue if potassium >5.5 mEq/L or creatinine doubles 1

4. SGLT2 Inhibitor (Fourth Pillar)

Initiate SGLT2 inhibitor (dapagliflozin 10 mg or empagliflozin 10 mg once daily) in all patients with HFrEF regardless of diabetes status. 1, 2

• Proven mortality benefit in both HFrEF and HFpEF 1
• Can be started simultaneously with other GDMT pillars 1
• Also indicated for primary prevention in patients with type 2 diabetes and high cardiovascular risk 1

Diuretic Therapy for Congestion

Administer furosemide 20-40 mg once or twice daily orally (or bumetanide 0.5-1 mg) and titrate to achieve euvolemia, then continue at lowest effective dose. 1

• Diuretics are essential for symptomatic relief but do not improve mortality 1, 2
• Titrate dose based on daily weights, aiming for 0.5-1 kg loss per day until euvolemic 1
• If inadequate response, increase loop diuretic dose, add thiazide (metolazone 2.5-10 mg), or switch to continuous IV infusion 1, 3
• Monitor electrolytes and renal function closely during dose adjustments 3

Additional Therapies for Selected Patients

Digoxin 0.125-0.25 mg once daily may be added at any time to reduce symptoms and hospitalizations, but does not reduce mortality. 1, 2

• Particularly beneficial in patients with atrial fibrillation 1, 6
• Monitor for toxicity, especially with renal impairment 2
• Reduce dose in elderly and those with reduced renal function 1

Hydralazine 37.5-75 mg three times daily plus isosorbide dinitrate 20-40 mg three times daily is particularly beneficial in African American patients with HFrEF. 1, 2

• Use as substitute when ACE inhibitors contraindicated due to hypotension or renal insufficiency 1
• Provides mortality benefit when added to standard therapy in African American patients 1

Device Therapy

Implantable cardioverter-defibrillator (ICD) for primary prevention is indicated in patients with LVEF ≤30-35%, NYHA Class II-III symptoms on optimal medical therapy for ≥3 months, and life expectancy >1 year. 1

• For ischemic cardiomyopathy, wait ≥40 days post-MI 1
• For non-ischemic cardiomyopathy, LVEF ≤30% required 1
• ICD for secondary prevention indicated after cardiac arrest or hemodynamically unstable ventricular tachycardia 1

Cardiac resynchronization therapy (CRT) is indicated in patients with LVEF ≤35%, sinus rhythm, NYHA Class II-IV symptoms on optimal medical therapy, and QRS ≥150 ms with left bundle branch block morphology. 1

• Consider CRT if QRS 120-149 ms with LBBB 1
• For patients requiring permanent pacing with high-degree AV block, use CRT over right ventricular pacing regardless of QRS duration 7

Management of Acute Decompensation

For hospitalized patients with acute heart failure, administer IV loop diuretics at doses equal to or exceeding chronic oral daily dose within 1 hour of presentation. 3, 7

• Furosemide 40-80 mg IV bolus or continuous infusion 3
• If inadequate diuresis, double the dose, add second diuretic (metolazone 2.5-10 mg), or switch to continuous infusion 3
• Monitor fluid intake/output, daily weights, vital signs, and continuous cardiac telemetry 3, 7
• Check electrolytes and renal function daily during IV diuretic use 3, 7

Administer supplemental oxygen to maintain SpO2 >90% and consider non-invasive ventilation (CPAP or BiPAP) for persistent hypoxia despite oxygen. 3, 7

For hypotension with hypoperfusion (cold extremities, oliguria, altered mental status, elevated lactate), administer IV dobutamine 2-20 mcg/kg/min. 3, 7

• Use only for hemodynamic support, not for symptom improvement alone 3
• Long-term intermittent inotrope infusions are contraindicated except for palliation in Stage D 1, 7

Continue ACE inhibitors and beta-blockers during hospitalization unless hemodynamically unstable. 3

• Initiate or restart beta-blockers only after euvolemia achieved and IV medications discontinued 3

Discharge Planning and Transition of Care

Provide written discharge instructions specifying: daily weight monitoring (call if gain >2-3 lbs in 1 day or 5 lbs in 1 week), sodium restriction to <2-3 g/day, fluid restriction to <2 L/day if hyponatremic, medication list with doses and timing, and follow-up appointments. 1, 3

Schedule follow-up visit within 7-14 days of discharge and telephone contact within 3 days. 3

Enroll patients in multidisciplinary heart failure disease management program to reduce rehospitalization and improve survival. 1, 3, 7

Management of HFpEF

For patients with LVEF ≥50%, focus on aggressive treatment of hypertension (target <130/80 mmHg), initiate SGLT2 inhibitor, and use diuretics judiciously for congestion. 1, 3

• SGLT2 inhibitors provide mortality benefit in HFpEF 1, 3
• Consider mineralocorticoid receptor antagonist for symptom management 3
• Treat atrial fibrillation with rate control 1
• No proven mortality benefit from ACE inhibitors, ARBs, or beta-blockers in HFpEF 1

Lifestyle Modifications and Non-Pharmacological Management

Restrict sodium intake to <2-3 g/day and measure weight daily at the same time. 1, 2

Encourage regular physical activity and exercise training in stable ambulatory patients (NYHA Class I-III) to improve functional capacity and quality of life. 1

• Avoid exercise during acute decompensation or suspected myocarditis 1
• Cardiac rehabilitation improves clinical status 1

Administer influenza and pneumococcal vaccines to reduce risk of respiratory infections. 1

Interventions NOT Recommended

Do NOT use the following interventions as they are ineffective or harmful: 1, 2

• Calcium channel blockers (except amlodipine for hypertension/angina) for treatment of heart failure 1, 7
• Long-term intermittent IV inotrope infusions except for palliation in Stage D 1, 7
• Nutritional supplements (coenzyme Q10, carnitine, taurine, antioxidants) 1, 2
• Hormonal therapies (growth hormone, thyroid hormone) 1, 2
• NSAIDs (cause sodium retention and blunt diuretic effects) 1, 7
• Most antiarrhythmic drugs (except amiodarone for symptomatic arrhythmias) 7

Monitoring and Follow-Up

Monitor the following parameters at each visit: 2, 3

• Symptoms (dyspnea, fatigue, orthopnea, paroxysmal nocturnal dyspnea, edema)
• Weight (daily by patient, at each visit by provider)
• Blood pressure and heart rate
• Volume status (jugular venous pressure, peripheral edema, pulmonary rales)
• Renal function (creatinine, eGFR) and electrolytes (sodium, potassium)
• Medication adherence and tolerance

Measure natriuretic peptides (BNP or NT-proBNP) at baseline and consider serial measurements to guide therapy and assess prognosis. 1, 7

Common Pitfalls to Avoid

• Do not delay initiation of all four GDMT pillars—start simultaneously or in rapid sequence rather than waiting months between additions 1, 2
• Do not discontinue beta-blockers during acute decompensation unless cardiogenic shock—reduce dose if needed but maintain therapy 3, 5
• Do not use ARBs instead of ACE inhibitors as first-line therapy—ARBs are for ACE inhibitor intolerance only 1
• Do not add ARB to ACE inhibitor plus MRA—triple renin-angiotensin-aldosterone system blockade increases hyperkalemia risk 1
• Do not use beta-blockers before ACE inhibitors—ACE inhibitors must be initiated first 1
• Do not accept suboptimal dosing—uptitrate all medications to target or maximally tolerated doses 1, 2