What is the best approach to treating Congestive Heart Failure (CHF)?

Treatment of Congestive Heart Failure

For patients with heart failure and reduced ejection fraction (HFrEF), initiate ACE inhibitors as first-line therapy combined with beta-blockers and diuretics, then add mineralocorticoid receptor antagonists if symptoms persist, and consider sacubitril/valsartan as a replacement for ACE inhibitors in those who remain symptomatic despite optimal therapy. 1

Initial Diagnostic Assessment

Before initiating treatment, confirm the diagnosis and classify the type of heart failure:

• Perform transthoracic echocardiography (TTE) to assess left ventricular ejection fraction (LVEF) and distinguish between HFrEF (LVEF ≤40%), HFmrEF (LVEF 41-49%), and HFpEF (LVEF ≥50%). 2
• Measure plasma natriuretic peptide levels to confirm the diagnosis, particularly in patients with acute dyspnea. 3
• Identify the underlying etiology (coronary artery disease, hypertension, valvular disease, cardiomyopathy) and any precipitating factors. 2

Pharmacological Treatment Algorithm for HFrEF

Step 1: ACE Inhibitors (First-Line Foundation)

Start ACE inhibitors immediately in all patients with reduced LVEF, beginning with low doses and titrating upward to target maintenance doses proven effective in clinical trials. 1, 4

Key implementation details:

• Review and potentially reduce diuretic doses 24 hours before initiating ACE inhibitors to minimize hypotension risk. 2, 4
• Start treatment in the evening when the patient is supine to minimize blood pressure drops. 2
• Monitor blood pressure, renal function (creatinine), and electrolytes (potassium) 1-2 weeks after each dose increase, at 3 months, then every 6 months. 1, 4
• Titrate to target doses used in clinical trials (e.g., enalapril 10 mg twice daily, lisinopril 20-40 mg daily). 4

Step 2: Beta-Blockers (Add Early)

Add beta-blockers for all stable patients with HFrEF (NYHA Class II-IV) who are already on ACE inhibitors and diuretics. 1, 4

• Beta-blockers reduce hospitalizations, improve functional class, prevent heart failure worsening, and improve survival. 1, 4
• Use agents proven effective in heart failure trials: carvedilol, metoprolol succinate, or bisoprolol. 4
• Start at very low doses and titrate slowly in stable patients; avoid initiation during acute decompensation. 4

Step 3: Diuretics (For Symptomatic Relief)

Administer diuretics when fluid overload is present, manifesting as pulmonary congestion or peripheral edema. 2, 1, 4

• Loop diuretics (furosemide, bumetanide, torsemide) are preferred for most patients with HFrEF. 4
• Always combine diuretics with ACE inhibitors; never use diuretics as monotherapy. 2, 4
• Titrate doses based on symptoms, daily weights, and clinical signs of congestion. 3
• For patients with reduced renal function (eGFR <30 mL/min), avoid thiazides except when used synergistically with loop diuretics. 4

Step 4: Mineralocorticoid Receptor Antagonists (MRAs)

Add spironolactone or eplerenone for patients who remain symptomatic (NYHA Class II-IV) despite ACE inhibitor and beta-blocker therapy to reduce heart failure hospitalization and death. 1, 4

Critical safety monitoring:

• Monitor serum potassium and creatinine carefully at initiation and during dose adjustments due to hyperkalemia risk. 4
• Avoid the combination of ACE inhibitor, ARB, and MRA due to excessive risk of renal dysfunction and hyperkalemia. 1
• Contraindicated if baseline potassium >5.0 mEq/L or creatinine >2.5 mg/dL. 4

Step 5: Sacubitril/Valsartan (ARNI)

Replace the ACE inhibitor with sacubitril/valsartan in ambulatory patients with HFrEF who remain symptomatic despite optimal treatment with ACE inhibitor, beta-blocker, and MRA. 1

• In the PARADIGM-HF trial, sacubitril/valsartan reduced the composite endpoint of cardiovascular death or heart failure hospitalization by 20% compared to enalapril (HR 0.80,95% CI 0.73-0.87, p<0.0001). 5
• Sacubitril/valsartan also reduced all-cause mortality (HR 0.84,95% CI 0.76-0.93, p=0.0009). 5
• Allow a 36-hour washout period after stopping ACE inhibitor before initiating sacubitril/valsartan to avoid angioedema. 5
• Target dose is 97/103 mg (sacubitril/valsartan) twice daily. 5

Device Therapy for HFrEF

Implantable Cardioverter-Defibrillators (ICDs)

Recommend ICD implantation for patients with symptomatic HF (NYHA Class II-III), LVEF ≤35%, and optimal medical therapy for at least 3 months to reduce sudden death and all-cause mortality. 1

Important caveats:

• Do not implant ICDs within 40 days of myocardial infarction, as this does not improve prognosis. 1
• ICDs are also indicated for patients who have survived ventricular arrhythmia causing hemodynamic instability. 1

Cardiac Resynchronization Therapy (CRT)

Recommend CRT for symptomatic heart failure patients in sinus rhythm with QRS duration ≥150 msec, left bundle branch block (LBBB) morphology, and LVEF ≤35% despite optimal medical therapy. 1

Treatment of Acute Decompensated Heart Failure

Initial Management

Administer IV loop diuretics as the cornerstone of acute decompensation treatment. 3

• For patients not on chronic oral diuretics, start with 20-40 mg IV furosemide. 3
• For patients on chronic diuretics, the initial IV dose should be at least equivalent to their oral dose. 3
• Administer either as intermittent boluses or continuous infusion based on response. 3

Managing Inadequate Diuretic Response

If diuresis is inadequate despite initial therapy, escalate treatment systematically: 3

1. Increase the dose of loop diuretics. 3
2. Add a second diuretic (metolazone, spironolactone, or IV chlorothiazide) for synergistic effect. 3
3. Consider continuous infusion of loop diuretics for persistent fluid retention. 3

Continuation of Chronic Therapies

Attempt to continue ACE inhibitors/ARBs and beta-blockers during hospitalization unless the patient is hemodynamically unstable (symptomatic hypotension or hypoperfusion). 3

• For patients not previously on evidence-based therapies, initiate them before hospital discharge. 3
• Avoid unnecessary discontinuation of disease-modifying therapies, as this is a common and harmful pitfall. 3

Monitoring During Acute Treatment

Monitor symptoms, urine output, renal function, and electrolytes regularly during IV diuretic use. 3

• Measure serum electrolytes, blood urea nitrogen, and creatinine daily during IV diuretic therapy or active medication titration. 3
• Assess vital signs, body weight, and clinical signs of perfusion and congestion daily. 3

Treatment of HFpEF and HFmrEF

The evidence for pharmacological therapy in heart failure with preserved ejection fraction (HFpEF) and mid-range ejection fraction (HFmrEF) is less robust than for HFrEF. 2

• Focus on treating underlying conditions: hypertension, coronary artery disease, atrial fibrillation, and diabetes. 2
• Use diuretics for symptomatic relief of congestion. 2
• The role of ARNIs, beta-blockers, and other agents in HFmrEF/HFpEF requires further research. 2

Non-Pharmacological Management

Patient Education and Self-Management

Provide comprehensive education about heart failure, symptom recognition (worsening dyspnea, weight gain >2-3 lbs in 1 day or 5 lbs in 1 week), and when to seek medical attention. 1, 4

• Instruct patients on daily weight monitoring and maintaining a weight log. 2, 1
• Explain the rationale for each medication and the importance of adherence. 2, 1

Dietary and Lifestyle Modifications

Control sodium intake, particularly in patients with severe heart failure, limiting to 2-3 grams daily. 1, 4

• Avoid excessive fluid intake in severe heart failure (typically limit to 1.5-2 liters daily). 1, 4
• Avoid excessive alcohol consumption; abstain completely if alcohol-induced cardiomyopathy is suspected. 2
• Strongly advise smoking cessation and offer nicotine replacement therapies. 2

Exercise and Physical Activity

Recommend daily physical activity in stable patients (NYHA Class II-III) to prevent muscle deconditioning and improve quality of life. 1, 4

• Exercise programs should include 10-15 minutes of warm-up, 20-30 minutes of aerobic and resistance exercise, and a cool-down period, performed 3-5 days per week. 6
• Do not encourage prolonged rest in stable conditions, as this worsens deconditioning. 2
• Consider formal cardiac rehabilitation programs for appropriate candidates. 6

Medications to Avoid in Heart Failure

Avoid the following medications that worsen heart failure outcomes:

• NSAIDs and COX-2 inhibitors increase the risk of heart failure worsening and hospitalization. 3
• Thiazolidinediones (glitazones) for diabetes increase heart failure risk. 3
• Diltiazem and verapamil (non-dihydropyridine calcium channel blockers) increase the risk of heart failure worsening in HFrEF. 1

Advanced and Refractory Heart Failure

For patients with persistent severe symptoms (NYHA Class IV) despite optimal medical and device therapy:

• Consider mechanical circulatory support (left ventricular assist devices) as bridge to transplantation or destination therapy. 2
• Evaluate for cardiac transplantation in appropriate candidates. 2
• Initiate palliative care discussions and consider hospice referral for patients not candidates for advanced therapies. 2

Common Pitfalls to Avoid

• Underdosing ACE inhibitors and beta-blockers: titrate to target doses proven in clinical trials, not just to symptom relief. 4
• Discontinuing beta-blockers during mild decompensation: continue unless hemodynamically unstable. 3
• Inadequate monitoring of electrolytes and renal function during diuretic therapy or medication titration. 3, 4
• Failing to provide adequate discharge planning, follow-up appointments, and enrollment in multidisciplinary heart failure management programs. 3
• Not confirming the diagnosis before labeling a patient as having refractory heart failure. 2