What is the initial treatment for heart failure?

Initial Treatment for Heart Failure

ACE inhibitors are the first-line pharmacological therapy for all patients with heart failure and reduced left ventricular systolic function, combined with diuretics when fluid overload is present. 1, 2, 3

Immediate Pharmacological Management

ACE Inhibitors (Foundation of Therapy)

• Start ACE inhibitors immediately in all patients with reduced ejection fraction, regardless of symptom severity 1, 2, 3
• Begin with low doses and titrate upward to target doses proven effective in clinical trials 1
• Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, then every 6 months 1, 2, 3
• Critical safety measures during initiation:
  • Avoid excessive diuresis before starting; reduce or withhold diuretics for 24 hours 1
  • Avoid potassium-sparing diuretics during initiation 1
  • Avoid NSAIDs completely 1, 2, 3
  • Stop treatment if renal function deteriorates substantially 1

Diuretics (For Symptomatic Relief)

• Essential for immediate symptom relief when pulmonary congestion or peripheral edema is present 1, 2, 3
• Loop diuretics (furosemide 20-40 mg IV) or thiazides for initial treatment 1, 3
• Always administer in combination with ACE inhibitors, never as monotherapy 1
• If GFR <30 mL/min, avoid thiazides except when used synergistically with loop diuretics 1
• Diuretics provide rapid improvement in dyspnea and exercise tolerance 1

Beta-Blockers (Add Early)

• Initiate beta-blockers in all stable patients with reduced ejection fraction (NYHA class II-IV) once ACE inhibitors and diuretics are established 1, 2, 3
• Use "start-low, go-slow" titration approach 3, 4
• Beta-blockers reduce mortality and hospitalization risk 1, 2, 3
• For heart failure, start metoprolol succinate at 12.5-25 mg once daily, doubling every 2 weeks up to 200 mg as tolerated 4

Diagnostic Confirmation Required

• Perform transthoracic echocardiography immediately to measure left ventricular ejection fraction and classify as HFrEF, HFmrEF, or HFpEF 2, 3
• Measure plasma natriuretic peptides (BNP or NT-proBNP) to confirm diagnosis and differentiate from non-cardiac dyspnea 2, 3
• Obtain ECG to assess for arrhythmias and conduction abnormalities 3

Additional Medications Based on Severity

For Advanced Heart Failure (NYHA III-IV)

• Add aldosterone receptor antagonist (spironolactone) to ACE inhibitor and diuretic regimen to improve survival 1, 2, 3
• Monitor potassium and creatinine closely: check after 5-7 days, then recheck every 5-7 days until stable 1

For Persistent Symptoms Despite Optimal Therapy

• Consider sacubitril/valsartan as replacement for ACE inhibitor in symptomatic patients already on ACE inhibitor and beta-blocker 2, 5
• Sacubitril/valsartan demonstrated superior reduction in cardiovascular death and heart failure hospitalization compared to enalapril (HR 0.80, p<0.0001) 5
• Target dose is 97/103 mg (marketed as 200 mg) twice daily 5

Digoxin (For Specific Indications)

• Add digoxin for patients with atrial fibrillation to control ventricular rate 1, 3
• Consider digoxin for persistent symptoms despite ACE inhibitor and diuretic therapy in sinus rhythm 1
• Use low doses (0.125-0.25 mg daily, targeting serum levels ≤1.0 ng/dL) 1

Critical Non-Pharmacological Interventions

Patient Education (Mandatory)

• Explain heart failure pathophysiology and symptom recognition 1, 2
• Teach daily self-weighing and when to seek medical attention 1
• Emphasize medication adherence 1

Lifestyle Modifications

• Sodium restriction for symptomatic patients 1, 2, 3
• Avoid excessive fluid intake in severe heart failure 1, 3
• Limit alcohol consumption 1, 3
• Smoking cessation mandatory 1
• Regular aerobic exercise in stable patients to prevent deconditioning and improve functional capacity 1, 2, 3

Medications to Absolutely Avoid

• NSAIDs and COX-2 inhibitors increase heart failure worsening and hospitalization risk 1, 2, 3
• Thiazolidinediones (glitazones) worsen heart failure 2, 3
• Non-dihydropyridine calcium channel blockers may be harmful with reduced ejection fraction 2

Common Pitfalls to Avoid

• Never use diuretics as monotherapy—always combine with ACE inhibitors to prevent neurohormonal activation 1
• Do not delay beta-blocker initiation once patient is stable on ACE inhibitors and diuretics 1, 2, 3
• Avoid over-diuresis before starting ACE inhibitors, which increases hypotension risk 1
• Do not use potassium-sparing diuretics during ACE inhibitor initiation due to hyperkalemia risk 1
• If transient worsening occurs during beta-blocker titration, increase diuretics and temporarily reduce beta-blocker dose rather than discontinuing 4

Treatment Algorithm Summary

1. Confirm diagnosis with echocardiography and natriuretic peptides 2, 3
2. Start ACE inhibitor immediately (low dose, titrate up) 1, 2, 3
3. Add diuretics if congestion present 1, 2, 3
4. Initiate beta-blocker once stable 1, 2, 3
5. Add aldosterone antagonist if NYHA III-IV 1, 2, 3
6. Consider sacubitril/valsartan if symptoms persist 2, 5
7. Implement lifestyle modifications and patient education 1, 2, 3