What is the initial management for a patient with Congestive Heart Failure (CHF)?

Initial Management of Congestive Heart Failure

All patients with symptomatic heart failure and reduced ejection fraction should be started on a combination of ACE inhibitors, beta-blockers, and diuretics, with ACE inhibitors initiated first, followed by beta-blockers once the patient is stabilized. 1

Immediate Assessment and Stabilization

Initial Evaluation

• Assess volume status by examining jugular venous pressure, peripheral edema, ascites, lung crackles, and orthostatic blood pressure changes 2, 3
• Obtain baseline laboratory tests: complete blood count, electrolytes (including calcium and magnesium), BUN, creatinine, fasting glucose, lipid profile, liver function tests, and thyroid-stimulating hormone 2, 3
• Perform 12-lead ECG and chest radiograph (PA and lateral) in all patients 2, 3
• Order two-dimensional echocardiography with Doppler to assess left ventricular ejection fraction, chamber size, wall thickness, and valve function 2, 3
• Consider BNP or NT-proBNP measurement when the clinical diagnosis is uncertain or for risk stratification 3

Fluid Management (First Priority if Congestion Present)

• Start loop diuretics immediately for any patient with signs or symptoms of fluid retention (elevated JVP, peripheral edema, pulmonary congestion) 2, 1
• Initiate furosemide 20-40 mg once or twice daily, bumetanide 0.5-1.0 mg, or torsemide 10-20 mg once daily 2
• Titrate diuretic dose upward until urine output increases and weight decreases by 0.5-1.0 kg daily 2
• Monitor daily weights, electrolytes, and renal function closely, especially after dose changes 2, 1
• For diuretic resistance, add a thiazide diuretic (metolazone 2.5-10 mg once daily or hydrochlorothiazide 25-100 mg) to the loop diuretic for sequential nephron blockade 2

Core Pharmacological Therapy

ACE Inhibitors (Initiate First)

Start ACE inhibitors at low doses in all patients with reduced ejection fraction (LVEF ≤35-40%), regardless of symptom severity, unless contraindicated. 2, 1

• Begin with low doses: enalapril 2.5 mg twice daily, lisinopril 2.5-5 mg daily, ramipril 2.5 mg daily, or captopril 6.25 mg three times daily 1
• Titrate slowly to target doses: enalapril 10-20 mg twice daily, lisinopril 20-35 mg daily, ramipril 5 mg twice daily, or captopril 50 mg three times daily 1
• Check renal function and electrolytes before treatment, 1-2 weeks after each dose increment, and at 3-6 month intervals 1
• Target doses are critical—the goal is to reach the doses proven effective in clinical trials, not just symptomatic improvement 2, 1

Common pitfall: Many clinicians use subtherapeutic ACE inhibitor doses. Studies show only a minority of patients achieve target doses in real-world practice, yet higher doses provide greater mortality benefit. 4

Beta-Blockers (Add After ACE Inhibitor Stabilization)

Initiate beta-blockers only after the patient is stable on ACE inhibitors and euvolemic (no signs of congestion). 2, 1

• Use only one of three proven beta-blockers: bisoprolol, carvedilol, or metoprolol CR/XL—other beta-blockers may be ineffective or harmful 2
• Start with low doses: bisoprolol 1.25 mg once daily, carvedilol 3.125 mg twice daily, or metoprolol CR/XL 12.5-25 mg once daily 2
• Double the dose at minimum 2-week intervals while monitoring heart rate, blood pressure, and clinical status 2
• Target doses: bisoprolol 10 mg once daily, carvedilol 25-50 mg twice daily, or metoprolol CR/XL 200 mg once daily 2
• Expect temporary worsening in 20-30% of patients during initiation—this does not mean the drug should be stopped 2

Critical caution: Do NOT start beta-blockers in patients with current or recent (within 4 weeks) decompensation, severe NYHA class IV symptoms, heart rate <60 bpm, heart block, or persistent signs of congestion (elevated JVP, ascites, marked edema). 2

Additional Medications to Consider

• Aldosterone antagonists (spironolactone 12.5-25 mg once daily) should be added in patients with NYHA class III-IV symptoms, preserved renal function (creatinine <2.5 mg/dL), and normal potassium (<5.0 mEq/L) 2
• Digoxin may be initiated at any time to reduce symptoms and enhance exercise tolerance, though it does not improve mortality 2
• SGLT2 inhibitors (dapagliflozin or empagliflozin) are recommended for patients with HFrEF or HFmrEF/HFpEF to reduce hospitalization and cardiovascular death 2

Medications to AVOID

Do NOT use the following in heart failure patients:

• Alpha-adrenergic blocking drugs—no evidence of benefit 2
• Calcium channel blockers (especially diltiazem and verapamil)—can worsen heart failure due to negative inotropic effects 2
• Class I antiarrhythmics—may provoke fatal ventricular arrhythmias and reduce survival 2
• NSAIDs or COX-2 inhibitors—increase risk of heart failure worsening and hospitalization 1

Non-Pharmacological Management

• Moderate sodium restriction (typically 2-3 grams daily) 2
• Daily weight monitoring by the patient, with instructions to contact provider if weight increases >2-3 pounds in 1-2 days 2
• Encourage physical activity except during acute decompensation—restriction promotes deconditioning and worsens exercise intolerance 2
• Influenza and pneumococcal vaccination to reduce risk of respiratory infections 2
• Patient education about expected benefits, potential temporary worsening with beta-blockers, and importance of medication adherence 2, 3

Follow-Up and Monitoring

• See patients within 1 week of hospital discharge by primary care provider and within 2 weeks by cardiology team 1
• Consider early telephone follow-up within 3 days of discharge 1
• Enroll in multidisciplinary heart failure management program to reduce hospitalization risk and improve survival 2, 1
• Monitor for worsening symptoms: increased dyspnea, fatigue, edema, or weight gain 3
• Adjust diuretic doses based on daily weights and clinical status—patients can often self-adjust within a prescribed range 2

Special Considerations for Coronary Disease

• Perform coronary arteriography in patients with angina or significant ischemia unless they are not candidates for revascularization 2
• Consider coronary arteriography in patients with chest pain of uncertain origin or known/suspected coronary disease without angina 2
• Noninvasive ischemia testing is reasonable in patients with known coronary disease to assess for viability and guide revascularization decisions 2