What are the guidelines for managing heart failure?

Guidelines for Managing Heart Failure

Core Pharmacological Therapy: The Four Pillars

All patients with heart failure and reduced ejection fraction (HFrEF) should receive quadruple therapy with ACE inhibitors (or ARNI), beta-blockers, aldosterone antagonists, and SGLT2 inhibitors as first-line treatment to reduce mortality and hospitalization. 1, 2

ACE Inhibitors (First Pillar)

• ACE inhibitors are mandatory for all patients with significantly reduced left ventricular ejection fraction unless contraindicated 3
• Start with low doses and titrate gradually to target doses proven in clinical trials over weeks to months 3, 2
• For lisinopril specifically: start at 5 mg once daily in heart failure patients (2.5 mg if hyponatremic with sodium <130 mEq/L), titrate up to maximum 40 mg daily 4
• Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, then every 6 months 3
• Avoid excessive diuresis before starting ACE inhibitors; reduce or withhold diuretics for 24 hours prior to initiation 3
• Avoid potassium-sparing diuretics during ACE inhibitor initiation 3
• Never use NSAIDs concurrently with ACE inhibitors 3
• Discontinuing or withdrawing ACE inhibitors during hospitalization increases 30-day mortality by 92% and 1-year mortality by 35% 5

Beta-Blockers (Second Pillar)

• Beta-blockers should be initiated in all stable HFrEF patients (NYHA class II-IV) after stabilization on diuretics and ACE inhibitors 3, 2
• Proven agents include bisoprolol, metoprolol succinate CR, carvedilol, and nebivolol 3, 2
• Carvedilol is preferred over metoprolol, demonstrating 38% mortality reduction and 17% greater mortality benefit compared to metoprolol tartrate 2, 6
• Start with very low doses: carvedilol 3.125 mg twice daily, bisoprolol 1.25 mg daily, metoprolol succinate 12.5-25 mg daily, or nebivolol 1.25 mg daily 3
• Double the dose every 1-2 weeks if tolerated 3, 2
• Target doses: carvedilol 25-50 mg twice daily, bisoprolol 10 mg daily, metoprolol succinate 200 mg daily, nebivolol 10 mg daily 3
• Patients must be relatively stable without intravenous inotropic therapy or marked fluid retention before starting beta-blockers 3
• If worsening symptoms occur during titration, first increase diuretics or ACE inhibitors before reducing beta-blocker dose 3
• For hypotension, reduce vasodilator doses first; only reduce beta-blocker dose if hypotension persists 3
• Never abruptly discontinue beta-blockers due to risk of rebound myocardial ischemia, infarction, and arrhythmias 3, 7

Aldosterone Antagonists (Third Pillar)

• Aldosterone antagonists (spironolactone) are indicated for NYHA class III-IV heart failure in addition to ACE inhibitors, beta-blockers, and diuretics to improve survival and reduce morbidity 3, 8
• Spironolactone is indicated for NYHA Class III-IV heart failure with reduced ejection fraction to increase survival, manage edema, and reduce hospitalization 8
• Only prescribe if renal function is preserved and potassium levels are normal 3
• Start with low-dose administration, check serum potassium and creatinine after 5-7 days, and titrate accordingly 3
• Recheck potassium every 5-7 days until values are stable 3
• Adding aldosterone antagonists to background ACE inhibitor/ARB therapy reduces mortality by 27% and hospitalization by 33% without significantly increasing discontinuation risk 9

Diuretics (Symptomatic Relief)

• Diuretics are essential for all patients with fluid overload manifesting as pulmonary congestion or peripheral edema 3
• Loop diuretics or thiazides should always be administered in addition to ACE inhibitors 3
• If glomerular filtration rate <30 mL/min, do not use thiazides except synergistically with loop diuretics 3
• For insufficient response: increase diuretic dose, combine loop diuretics with thiazides, or administer loop diuretics twice daily 3
• In severe chronic heart failure with persistent fluid retention, add metolazone with frequent creatinine and electrolyte monitoring 3
• Diuretics provide rapid improvement in dyspnea and increased exercise tolerance but have not been proven to reduce mortality 3

Alternative Therapies When ACE Inhibitors Not Tolerated

• Angiotensin receptor blockers (ARBs) are indicated as an alternative to ACE inhibitors in symptomatic patients intolerant to ACE inhibitors 3, 2
• ARBs and ACE inhibitors have similar efficacy on mortality and morbidity in heart failure 3
• However, ARBs combined with beta-blockers lack the same evidence base as ACE inhibitors with beta-blockers, except for candesartan 10
• Hydralazine plus isosorbide dinitrate should be used in patients who cannot take ACE inhibitors 3, 2

Digoxin

• Digoxin is indicated for patients with heart failure due to systolic dysfunction not adequately responsive to ACE inhibitors and diuretics 3
• Digoxin is mandatory for patients with atrial fibrillation and rapid ventricular rates to slow ventricular rate and improve symptoms 3
• Usual daily dose: 0.125-0.25 mg if serum creatinine is normal (0.0625-0.125 mg in elderly) 3
• Digoxin improves symptoms and clinical status but does not reduce mortality 2

Anticoagulation

• Anticoagulation is required for patients with atrial fibrillation or previous history of systemic or pulmonary embolism 3
• Consider anticoagulation in patients with sinus rhythm who have very low ejection fraction or intracardiac thrombi 3

Refractory Heart Failure (Stage D)

• Before declaring heart failure refractory, confirm diagnostic accuracy, identify and reverse contributing conditions, and ensure all conventional medical strategies have been optimally employed 2
• Hospital admission is indicated when patients become refractory to therapy, particularly with progressive symptoms and inadequate oral diuretic response 3
• Short periods of bed rest alone may produce diuresis 3
• Change from oral to intravenous diuretics may be effective 3
• Low-dose dobutamine (2-5 µg/kg/min) or intravenous milrinone (50 µg/kg loading dose, then 0.375-0.75 µg/kg/min) may temporarily improve cardiac output and renal blood flow 3
• If inotropic support is needed in patients on beta-blockers, use phosphodiesterase inhibitors rather than dobutamine because their effects are not antagonized by beta-blockade 3, 6
• For confirmed refractory disease, consider mechanical circulatory support, continuous intravenous positive inotropic therapy, cardiac transplantation evaluation, or hospice care 1, 2

Therapies to Avoid

• Do NOT use calcium channel blockers in the absence of coexistent angina or hypertension 3, 2
• Do NOT treat asymptomatic ventricular arrhythmias 3
• Do NOT use long-term intermittent infusions of positive inotropic drugs 2
• Do NOT use NSAIDs in heart failure patients on ACE inhibitors or with fluid retention 2
• Do NOT routinely use nutritional supplements or hormonal therapies 2

Non-Pharmacological Management

• Sodium restriction is essential for symptomatic patients to reduce congestive symptoms 2
• Avoid excessive fluid intake in severe heart failure 3
• Avoid excessive alcohol intake 3
• Moderate dynamic exercise (walking, recreational biking) should be strongly encouraged to tolerance; avoid isometric exercise (push-ups, weightlifting) 3, 2
• Exercise training programs are recommended for stable NYHA class II-III patients to improve clinical status 3, 2
• Daily self-weighing and symptom monitoring are essential 3
• Smoking cessation is mandatory; nicotine replacement therapies are acceptable 3

Initial Diagnostic Workup

• Obtain complete blood count, urinalysis, serum electrolytes, BUN, creatinine, fasting glucose, glycohemoglobin, lipid profile, liver function tests, and TSH 2
• Perform 12-lead ECG and chest radiograph (PA and lateral) 2
• Two-dimensional echocardiography with Doppler should assess left ventricular ejection fraction, LV size, wall thickness, and valve function 2
• Plasma natriuretic peptides are most useful as a "rule out" test due to high negative predictive values 3

Dose Adjustments for Renal Impairment

• For lisinopril with creatinine clearance 10-30 mL/min: reduce initial dose to 2.5 mg for heart failure, titrate to maximum 40 mg daily 4
• For hemodialysis or creatinine clearance <10 mL/min: initial lisinopril dose is 2.5 mg once daily 4

Common Pitfalls to Avoid

• Do not withhold or discontinue ACE inhibitors or beta-blockers during hospitalization unless absolutely necessary, as this dramatically increases mortality 5
• Do not assume ARBs and ACE inhibitors are interchangeable when combined with beta-blockers; ACE inhibitors have superior evidence 10
• Nurse-led titration protocols increase the proportion of patients reaching target doses and reduce hospital admissions 11
• Starting all four pillar drugs together at low doses is emerging as a preferred approach rather than sequential initiation 12