What is the treatment for Congestive Heart Failure (CHF)?

Treatment of Congestive Heart Failure

All patients with heart failure and reduced ejection fraction (HFrEF, LVEF ≤40%) should receive four foundational medication classes simultaneously: ACE inhibitors (or ARNIs), beta-blockers, mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors, as this combination reduces mortality and hospitalization. 1

Initial Pharmacological Approach for HFrEF

ACE Inhibitors (First-Line Therapy)

• Start ACE inhibitors immediately in all patients with reduced left ventricular systolic function, beginning with low doses and gradually titrating to target maintenance doses proven effective in clinical trials 2, 3
• Before initiating ACE inhibitors, review and potentially reduce diuretic doses for 24 hours to avoid excessive hypotension 2
• Target doses from major trials: lisinopril 20-35 mg daily, enalapril 10-20 mg twice daily, or ramipril 5-10 mg daily 4, 5
• Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, and subsequently at 6-month intervals 2, 3
• High-dose ACE inhibitor therapy can be successfully titrated and maintained in over 90% of patients, including those with baseline hypotension, renal dysfunction, advanced age, or diabetes 5

Beta-Blockers (Mandatory Co-Therapy)

• Initiate beta-blockers in all stable patients already on ACE inhibitors and diuretics, ensuring the patient has no intravenous inotropic support requirements or marked fluid retention 4, 1
• Evidence-based beta-blockers with proven mortality benefit: bisoprolol (target 10 mg daily), metoprolol succinate CR (target 200 mg daily), carvedilol (target 50 mg daily), or nebivolol (target 10 mg daily) 4
• Start with very low doses (bisoprolol 1.25 mg, metoprolol 12.5-25 mg, carvedilol 3.125 mg) and double the dose every 1-2 weeks if tolerated 4, 1
• Beta-blockers reduce mortality by at least 20% and decrease hospitalizations 1

Managing Beta-Blocker Titration Complications

• If worsening heart failure symptoms occur: first increase diuretics or ACE inhibitor dose before reducing beta-blocker 4, 1
• If hypotension develops: first reduce vasodilator doses rather than the beta-blocker 4, 1
• If symptomatic bradycardia occurs: reduce or discontinue other heart rate-lowering drugs before adjusting beta-blocker, and only discontinue beta-blocker if clearly necessary 4
• Always attempt reintroduction and uptitration once the patient stabilizes 4
• If inotropic support is needed in a beta-blocked patient, use phosphodiesterase inhibitors as their effects are not antagonized by beta-blockers 4, 1

Mineralocorticoid Receptor Antagonists (MRAs)

• Add spironolactone or eplerenone for patients who remain symptomatic (NYHA Class III-IV) despite ACE inhibitor and beta-blocker therapy to reduce mortality and hospitalization 4, 3
• Start spironolactone 12.5-25 mg daily or eplerenone 25 mg daily only if serum potassium <5.0 mmol/L and creatinine <250 μmol/L 4, 1
• Check potassium and creatinine after 4-6 days of initiation 4, 1
• If potassium rises to 5.0-5.5 mmol/L: reduce dose by 50%; if >5.5 mmol/L: stop the medication 4
• After 1 month, if symptoms persist and potassium remains normal, increase to 50 mg daily with repeat monitoring after 1 week 4

SGLT2 Inhibitors (Fourth Pillar)

• Initiate SGLT2 inhibitors early in all HFrEF patients regardless of diabetes status to reduce cardiovascular death and heart failure hospitalization 1

Diuretic Therapy

• Diuretics are essential for symptomatic relief when fluid overload is present (pulmonary congestion or peripheral edema) 4, 3
• Loop diuretics or thiazides should always be administered in combination with ACE inhibitors 2
• Avoid thiazides in patients with reduced renal function except when used synergistically with loop diuretics 2

Advanced Therapy: Sacubitril/Valsartan (ARNI)

• Replace ACE inhibitors with sacubitril/valsartan in ambulatory patients who remain symptomatic despite optimal therapy with ACE inhibitor, beta-blocker, and MRA 4, 3
• This substitution further reduces heart failure hospitalization and death 4

Alternative Agents for ACE Inhibitor Intolerance

• If ACE inhibitors are not tolerated, use angiotensin receptor blockers (ARBs) as they have similar efficacy on mortality and morbidity 4
• The combination of hydralazine/nitrates can be tried if both ACE inhibitors and ARBs are not tolerated 4

Digoxin (Adjunctive Therapy)

• Reserve digoxin for patients with persistent symptoms despite ACE inhibitor, beta-blocker, and diuretic therapy, or for rate control in atrial fibrillation 4, 1
• Usual dose: 0.125-0.25 mg daily with normal renal function; 0.0625-0.125 mg in elderly patients 4
• Contraindications: bradycardia, second- or third-degree AV block, sick sinus syndrome, carotid sinus syndrome, Wolff-Parkinson-White syndrome, hypertrophic obstructive cardiomyopathy, and electrolyte abnormalities 4, 1

Ivabradine (Heart Rate Reduction)

• Consider ivabradine in patients with HFrEF, LVEF ≤35%, sinus rhythm with heart rate ≥70 bpm despite maximally tolerated beta-blocker doses 6
• Start at 5 mg twice daily and titrate to maintain heart rate 50-60 bpm 6
• Ivabradine reduces hospitalization for worsening heart failure but does not reduce cardiovascular mortality 6

Device Therapy

Implantable Cardioverter-Defibrillators (ICDs)

• ICD is indicated for primary prevention in symptomatic HF (NYHA Class II-III) with LVEF ≤35% despite ≥3 months of optimal medical therapy in patients with ischemic heart disease or dilated cardiomyopathy 4, 3
• ICD is indicated for secondary prevention in patients who survived ventricular arrhythmia causing hemodynamic instability 4, 3
• Do not implant ICD within 40 days of myocardial infarction as it does not improve prognosis during this period 4, 3

Cardiac Resynchronization Therapy (CRT)

• CRT is indicated for symptomatic HF patients in sinus rhythm with QRS duration ≥150 msec, LBBB morphology, and LVEF ≤35% despite optimal medical therapy 4, 3
• CRT improves symptoms and reduces morbidity and mortality 4

Treatment by Ejection Fraction Category

Heart Failure with Mildly Reduced EF (HFmrEF, LVEF 41-49%)

• Treat similarly to HFrEF with the same four-drug foundational therapy, though evidence level is lower 1

Heart Failure with Preserved EF (HFpEF, LVEF ≥50%)

• SGLT2 inhibitors are the cornerstone of HFpEF treatment, reducing cardiovascular death and heart failure hospitalization 1

Medications to Avoid

• Never use diltiazem or verapamil in HFrEF as they increase risk of heart failure worsening and hospitalization 4
• Avoid combining ACE inhibitor, ARB, and MRA due to increased risk of renal dysfunction and hyperkalemia 4, 1
• Direct-acting vasodilators have no specific role in CHF treatment except as adjunctive therapy for angina or hypertension 4

Non-Pharmacological Management

• Provide patient education about heart failure, symptom recognition, and self-management 2, 3
• Recommend daily physical activity in stable patients to prevent muscle deconditioning and improve exercise tolerance 2, 3
• Control sodium intake, especially in severe heart failure 2, 3
• Avoid excessive fluid intake in severe heart failure 2, 3
• Team-based care with cardiologists, primary care physicians, nurses, and pharmacists reduces mortality and hospitalization 1

Specialist Referral Indications

Refer to heart failure specialist for: 4, 1

• Severe heart failure (NYHA Class III/IV)
• Unknown etiology
• Relative contraindications to beta-blockers (asymptomatic bradycardia, low blood pressure)
• Intolerance to low doses of standard medications
• Previous beta-blocker discontinuation due to symptoms
• Suspected bronchial asthma or severe pulmonary disease