What is the initial management for congestive heart failure?

Initial Management of Congestive Heart Failure

Start all patients with symptomatic heart failure and reduced ejection fraction on the combination of an ACE inhibitor (or ARB if intolerant) plus a diuretic for immediate symptom relief, then add a beta-blocker once stable. 1, 2

Immediate First-Line Pharmacotherapy

Diuretics for Congestion

• Loop diuretics (or thiazides if GFR >30 mL/min) are essential first-line therapy when fluid overload is present, manifesting as pulmonary congestion or peripheral edema 1, 2
• Diuretics produce rapid improvement in dyspnea and increased exercise tolerance within hours to days 1
• Always administer diuretics in combination with an ACE inhibitor, never as monotherapy, as diuretics alone increase plasma renin activity, angiotensin II, aldosterone, and norepinephrine levels 1, 3
• If insufficient response: increase the diuretic dose, combine loop diuretics with thiazides, or administer loop diuretics twice daily 1
• In severe chronic heart failure with persistent fluid retention, add metolazone with frequent measurement of creatinine and electrolytes 1

ACE Inhibitors as Foundation Therapy

• ACE inhibitors are recommended for all patients with heart failure and reduced left ventricular ejection fraction (<40-45%), regardless of symptom severity 1, 2
• ACE inhibitors reduce mortality, reduce hospitalization, reduce symptoms, and increase exercise capacity 1, 4
• Start with a low dose and uptitrate to the target dosages shown effective in large trials, not based on symptomatic improvement alone 1

Specific ACE Inhibitor Initiation Protocol: 1

1. Review and reduce diuretic dose if excessive diuresis has occurred; withhold diuretics for 24 hours before starting
2. Consider starting treatment in the evening when supine to minimize hypotension risk
3. Start with low dose and build up to recommended maintenance dosages
4. Avoid potassium-sparing diuretics during initiation
5. Avoid NSAIDs completely
6. Check blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, and subsequently at 6-month intervals

• If renal function deteriorates substantially (creatinine increase >30%), stop treatment 1
• If ACE inhibitors cause intolerable cough or angioedema, switch to an ARB 1
• If both ACE inhibitors and ARBs are not tolerated, use combination hydralazine and isosorbide dinitrate 1, 3, 5

Beta-Blockers as Early Add-On Therapy

• Beta-blockers are recommended for all patients with stable heart failure (NYHA class II-IV) and reduced ejection fraction once initial stabilization with ACE inhibitor and diuretic is achieved 1, 2
• Beta-blockers reduce mortality in all age groups including elderly patients (≥65 years) 1
• Use only evidence-based beta-blockers: bisoprolol, metoprolol succinate (long-acting), carvedilol, or nebivolol 1
• Introduce in a "start-low, go-slow" manner with heart rate, blood pressure, and clinical status reviewed after each dose titration 1
• High-quality evidence shows the same outcomes whether ACE inhibitor or beta-blocker is started first 1

Second-Line Therapies for Persistent Symptoms

Aldosterone Receptor Antagonists

• Spironolactone is recommended in advanced heart failure (NYHA class III-IV) in addition to ACE inhibition and diuretics to improve survival and reduce morbidity 1, 2, 6
• Start with low-dose administration (typically 25 mg daily) 1
• Check serum potassium and creatinine after 5-7 days and titrate accordingly; recheck every 5-7 days until potassium values are stable 1
• Close monitoring of potassium levels and renal function is mandatory 1

Angiotensin Receptor Blockers (ARBs) as Add-On

• ARBs reduce hospitalizations for heart failure and improve quality of life but do not have statistically significant effect on survival as monotherapy 1
• Adding ARBs to ACE inhibitors and beta-blockers reduces cardiovascular mortality and hospitalization for heart failure 1
• Combination therapy with ARBs and ACE inhibitors increases risk for hyperkalemia and elevated serum creatinine, requiring close monitoring 1

Sacubitril/Valsartan for Advanced Cases

• For patients who remain symptomatic despite optimal treatment with ACE inhibitor and beta-blocker, consider sacubitril/valsartan as replacement for ACE inhibitor 2, 7
• Sacubitril/valsartan demonstrated superiority over enalapril in reducing cardiovascular death or heart failure hospitalization (HR 0.80, p<0.0001) 7
• Improved overall survival (HR 0.84, p=0.0009) driven by lower cardiovascular mortality 7

Critical Monitoring Parameters

• Blood pressure, renal function (creatinine, eGFR), and electrolytes (potassium) at baseline, 1-2 weeks after each dose change, at 3 months, then every 6 months 1, 2
• Daily weight monitoring by patient for early detection of fluid retention 1
• Urine output monitoring during diuretic therapy 2

Essential Non-Pharmacological Management

Patient Education (Mandatory)

• Explain what heart failure is and why symptoms occur 1, 2
• Teach recognition of worsening symptoms and when to seek care 1
• Emphasize importance of medication adherence 1
• Instruct on daily self-weighing technique 1

Lifestyle Modifications

• Sodium restriction is recommended for symptomatic patients to reduce congestive symptoms 1, 2
• Avoid excessive fluid intake in severe heart failure 1
• Avoid excessive alcohol intake 1
• Regular aerobic exercise is recommended in stable patients (NYHA class II-III) to improve functional capacity and prevent muscle deconditioning 1, 2
• Rest is not encouraged in stable conditions 1
• Smoking cessation with nicotine replacement therapies if needed 1

Medications to Strictly Avoid

• NSAIDs and COX-2 inhibitors increase risk of heart failure worsening and hospitalization 1, 2
• Thiazolidinediones (glitazones) increase risk of heart failure worsening 2
• Non-dihydropyridine calcium channel blockers may be harmful in patients with low ejection fraction 2
• Avoid potassium-sparing diuretics during ACE inhibitor initiation 1

Common Pitfalls to Avoid

• Never use diuretics as monotherapy long-term without ACE inhibitor or ARB, as this activates deleterious neurohormonal systems 1, 3
• Do not undertitrate ACE inhibitors or beta-blockers based solely on symptom improvement; target the evidence-based doses from clinical trials 1
• Do not readily switch from ACE inhibitor to ARB for minor side effects; the evidence base is stronger for ACE inhibitors, so switch only for intolerable cough or angioedema 1
• Do not add aldosterone antagonists without close potassium and renal function monitoring, as hyperkalemia risk is significant especially with concurrent ACE inhibitor/ARB therapy 1
• Do not use thiazides if GFR <30 mL/min except synergistically with loop diuretics 1