What are the guidelines for managing Congestive Heart Failure (CHF)?

Management of Congestive Heart Failure: Evidence-Based Guidelines

All patients with heart failure and reduced ejection fraction (HFrEF) should receive a foundational regimen of ACE inhibitors (or ARBs if intolerant), beta-blockers, and diuretics as needed for fluid management, with aldosterone antagonists added for patients with persistent severe symptoms. 1

Staging and Initial Assessment

The American Heart Association uses a progressive staging system (A through D) to guide treatment intensity 1:

• Stage A: High risk without structural heart disease or symptoms
• Stage B: Structural heart disease without symptoms
• Stage C: Structural heart disease with prior or current symptoms
• Stage D: Refractory heart failure with marked symptoms at rest despite maximal therapy

Required Initial Workup

When evaluating new heart failure patients, obtain 1:

• Complete blood count, urinalysis, serum electrolytes, BUN, creatinine
• Fasting glucose, glycohemoglobin, lipid profile, liver function tests, TSH
• 12-lead ECG and chest radiograph (PA and lateral)
• Two-dimensional echocardiography with Doppler to assess LVEF, LV size, wall thickness, and valve function 1

Core Pharmacological Management

ACE Inhibitors: First-Line Therapy

ACE inhibitors are recommended as first-line therapy for all patients with reduced LV systolic function. 2, 1

Initiation protocol 2:

• Review and potentially reduce diuretics 24 hours before starting
• Start with low doses and titrate gradually to target doses proven in clinical trials 1
• Monitor renal function and potassium levels during titration 1
• Diuretics should always be administered in combination with ACE inhibitors if possible 2

If ACE inhibitors are not tolerated, use angiotensin receptor blockers (ARBs) in patients already on digitalis, diuretics, and beta-blockers 1. ARBs have significantly fewer side effects, notably less cough than ACE inhibitors 2.

Beta-Blockers: Mortality Reduction

Beta-blockers reduce sudden death in heart failure and should be initiated in all stable HFrEF patients after stabilization on diuretics and ACE inhibitors. 2, 1

Proven agents include 1, 3:

• Bisoprolol
• Metoprolol succinate (extended-release)
• Carvedilol (demonstrated 38% mortality reduction and 31% reduction in death/hospitalization at 12 months) 3
• Nebivolol

Initiation protocol 2:

• Patients should be on background ACE inhibition if not contraindicated
• Patient must be relatively stable without need for IV inotropic therapy and without marked fluid retention
• Start with very low dose and titrate up to maintenance dosages shown effective in large trials
• Double dose every 1-2 weeks if preceding dose well tolerated 1
• Most patients can be managed as outpatients

Monitoring during titration 2:

• Watch for transient worsening failure, hypotension, or bradycardia
• If worsening symptoms: first increase diuretics or ACE-inhibitor dose; temporarily reduce beta-blocker if necessary
• If hypotension: first reduce vasodilator dose; reduce beta-blocker if necessary
• Always consider reintroduction/uptitration when patient becomes stable

Absolute contraindications 2:

• Asthma bronchiale
• Severe bronchial disease
• Symptomatic bradycardia or hypotension

Diuretics: Symptomatic Relief

Diuretics are essential for symptomatic treatment when fluid overload is present, manifesting as pulmonary congestion or peripheral edema. 2

• Loop diuretics (furosemide) are first-line for acute exacerbations with edema, providing rapid dyspnea improvement 1
• Doses should be adjusted to achieve and maintain euvolemia 1
• Use results in rapid improvement of dyspnea and increased exercise tolerance 2

For diuretic resistance 4:

• Consider low-dose dopamine infusion
• Add thiazide or spironolactone as combination therapy

Aldosterone Antagonists: Advanced Heart Failure

Spironolactone should be added for patients with recent or current NYHA class III-IV symptoms who have preserved renal function and normal potassium levels. 2, 1

Administration protocol 2:

1. Confirm patient is in severe heart failure (NYHA III/IV) despite ACE inhibition/diuretics
2. Check serum potassium (<5.0 mmol/L) and creatinine (<250 mmol/L)
3. Add 25 mg spironolactone daily
4. Check serum potassium and creatinine after 4-6 days
5. If serum potassium ≥5.5 mmol/L, reduce dose by 50% or stop

For eplerenone (alternative aldosterone antagonist) 5:

• Initiate at 25 mg once daily in post-MI HFrEF patients
• Titrate to 50 mg once daily within 4 weeks as tolerated
• Contraindicated if serum potassium >5.5 mEq/L, creatinine clearance ≤30 mL/min, or concurrent strong CYP3A inhibitors
• Monitor potassium before initiation, within first week, and at one month

Digoxin: Symptom Management

Digoxin is indicated in atrial fibrillation with any degree of symptomatic heart failure to slow ventricular rate, improving ventricular function and symptoms. 2

In sinus rhythm, digoxin improves clinical status in patients with persisting symptoms despite ACE inhibitor and diuretic treatment 2. However, digoxin does not reduce mortality 1.

Dosing 2:

• Usual daily dose: 0.25-0.375 mg if serum creatinine normal
• Elderly: 0.125-0.25 mg daily
• No loading dose needed for chronic conditions
• Combination of digoxin and beta-blockade appears superior to either alone 2

Contraindications 2:

• Bradycardia
• Second- and third-degree AV-block
• Sick sinus syndrome
• Carotid sinus syndrome
• Hypokalemia and hypercalcemia

Medications to AVOID

Class I anti-arrhythmics should be avoided as they may provoke fatal ventricular arrhythmias, have adverse hemodynamic effects, and reduce survival. 2

Calcium antagonists are not recommended for heart failure caused by systolic dysfunction. 2 Diltiazem- and verapamil-type calcium antagonists in particular are not recommended 2.

Alpha-adrenergic blocking drugs have no evidence to support their use in heart failure. 2

Do NOT use 1:

• Long-term intermittent infusions of positive inotropic drugs
• Calcium channel blockers as treatment for heart failure
• Nutritional supplements or hormonal therapies routinely
• NSAIDs in heart failure patients on ACE inhibitors or with fluid retention

Aspirin should be avoided in patients with recurrent hospitalization with worsening heart failure. 2

Anti-Arrhythmic Management

Amiodarone is effective against most supraventricular and ventricular arrhythmias and is the only anti-arrhythmic drug without clinically relevant negative inotropic effects. 2

• May restore and maintain sinus rhythm in patients with atrial fibrillation even with enlarged left atria 2
• Improves success of electrical cardioversion 2
• However, routine administration in patients with heart failure is not justified 2

Non-Pharmacological Management

Patient Education and Self-Management 2

Essential education components:

• Explain what heart failure is and why symptoms occur
• How to recognize symptoms and what to do if they occur
• Daily self-weighing
• Rationale of treatments and importance of adherence
• Refrain from smoking; use nicotine replacement therapies if needed

Lifestyle Modifications 2, 1

• Sodium restriction is essential for symptomatic patients to reduce congestive symptoms 1
• Avoid excessive fluids in severe HF 2
• Avoid excessive alcohol intake 2
• Exercise training should be implemented as adjunctive approach to improve clinical status in ambulatory patients 1
• Rest not encouraged in stable conditions 2
• Daily physical and leisure activities in stable patients to prevent muscle deconditioning 2

Surgical and Device Considerations

Revascularization

Until results of randomized trials are reported, revascularization (surgical or percutaneous) is not recommended as routine management of patients with heart failure and coronary disease. 2

Single-center observational studies suggest revascularization might lead to symptomatic improvement in ischemic heart failure 2.

Mitral Valve Surgery

Mitral valve surgery in patients with severe LV systolic dysfunction and severe mitral insufficiency may lead to symptomatic improvement in selected patients. 2 This applies to both primary mitral insufficiency and secondary insufficiency due to LV dilatation 2.

LV Aneurysmectomy

LV aneurysmectomy is indicated in patients with large, discrete left ventricular aneurysms who develop heart failure. 2

Stage D: Refractory Heart Failure

Before declaring heart failure refractory, confirm diagnostic accuracy, identify and reverse contributing conditions, and ensure all conventional medical strategies have been optimally employed. 1

For confirmed refractory disease, consider 1:

• Mechanical circulatory support
• Continuous intravenous positive inotropic therapy
• Cardiac transplantation evaluation
• Hospice care

If inotropic support is needed in a patient on beta-blockade, phosphodiesterase inhibitors should be preferred because their hemodynamic effects are not antagonized by beta-blockers. 2

Anticoagulation Considerations

Patients with CHF are at high risk of thromboembolic events due to low cardiac output, dilated cardiac chambers, poor contractility, regional wall motion abnormalities, and atrial fibrillation. 2

However, rates of thromboembolic complications in heart failure are sufficiently low to limit evaluation of any potential beneficial effect of anti-coagulation therapy 2. There is little evidence to support concomitant treatment with ACE-inhibitor and aspirin in heart failure 2.

Anti-coagulant therapy should be administered under the most controlled conditions with monitoring in properly managed anti-coagulation clinics. 2

Monitoring and Follow-Up

Measure serum potassium before starting therapy and periodically thereafter, especially when initiating aldosterone antagonists or adjusting doses. 1, 5

Check serum potassium and creatinine within 3-7 days of patient initiating 5:

• Moderate CYP3A inhibitor
• ACE inhibitors
• Angiotensin-II blockers
• Non-steroidal anti-inflammatories

Common Pitfalls

• Underdosing ACE inhibitors and beta-blockers: Target doses proven in clinical trials, not just symptom relief 1
• Premature discontinuation of beta-blockers during decompensation: Reduce dose temporarily rather than stopping completely 2
• Failure to monitor potassium with aldosterone antagonists: Can lead to life-threatening hyperkalemia 5
• Using calcium channel blockers for rate control: Use beta-blockers or digoxin instead 2
• Neglecting patient education: Self-monitoring and adherence are critical for preventing decompensation 2, 1