What are the treatment guidelines for patients with heart failure?

Heart Failure Treatment Pearls

All patients with heart failure and reduced ejection fraction should be started on ACE inhibitors as first-line therapy, followed by beta-blockers once stable, with diuretics added for symptomatic fluid overload. 1, 2

Core Pharmacological Foundation

ACE Inhibitors - The Cornerstone

• Start ACE inhibitors immediately in all patients with reduced left ventricular systolic function to reduce mortality and hospitalizations 1, 2, 3
• Begin with low doses and titrate gradually to target maintenance doses proven effective in large trials 4, 2, 3
• Before initiating, reduce or withhold diuretics for 24 hours if possible to avoid excessive hypotension 3
• Monitor blood pressure, renal function, and electrolytes at 1-2 weeks after each dose increment, at 3 months, then every 6 months 4, 2
• Avoid potassium-sparing diuretics during ACE inhibitor initiation 4, 3
• Avoid NSAIDs completely as they antagonize ACE inhibitor effects 4, 3

For ACE-intolerant patients: ARBs are an acceptable alternative with similar efficacy on mortality and morbidity 4

Beta-Blockers - Essential Add-On Therapy

• Add beta-blockers to all stable patients (NYHA class II-IV) already on ACE inhibitors and diuretics 4, 1, 2
• Patient must be relatively stable without need for IV inotropes and without marked fluid retention before starting 4
• Use evidence-based agents with proven mortality benefit 4:
  • Bisoprolol: Start 1.25 mg, target 10 mg daily
  • Metoprolol succinate CR: Start 12.5-25 mg, target 200 mg daily
  • Carvedilol: Start 3.125 mg, target 50 mg daily
  • Nebivolol: Start 1.25 mg, target 10 mg daily
• Double the dose every 1-2 weeks if the preceding dose was well tolerated 4

Critical management during beta-blocker titration 4:

• If worsening symptoms occur, first increase diuretics or ACE inhibitor dose before reducing beta-blocker
• If hypotension develops, first reduce vasodilator doses before reducing beta-blocker
• If bradycardia occurs, reduce or discontinue other rate-lowering drugs first; only discontinue beta-blocker if clearly necessary
• Always attempt reintroduction and uptitration once patient stabilizes

Diuretics - For Symptomatic Relief

• Use diuretics for all patients with fluid overload (pulmonary congestion or peripheral edema), always in combination with ACE inhibitors 1, 2, 3
• Loop diuretics or thiazides for initial treatment 4
• If GFR <30 ml/min, avoid thiazides except when combined synergistically with loop diuretics 4
• For insufficient response: increase diuretic dose, combine loop diuretics with thiazides, or administer loop diuretics twice daily 4
• In severe chronic heart failure with persistent fluid retention, add metolazone with frequent monitoring of creatinine and electrolytes 4

Aldosterone Antagonists - For Advanced Disease

• Add spironolactone for advanced heart failure (NYHA III-IV) in patients already on ACE inhibitors and diuretics to improve survival and reduce morbidity 4, 1, 2
• Start with low-dose administration, check serum potassium and creatinine after 5-7 days, and titrate accordingly 4
• Recheck every 5-7 days until potassium values are stable 4

Cardiac Glycosides - Specific Indications

• Digoxin is indicated for all patients with atrial fibrillation and any degree of symptomatic heart failure to slow ventricular rate and improve symptoms 4
• In sinus rhythm, use digoxin for patients with persistent symptoms despite ACE inhibitor and diuretic treatment 4
• Usual dose: 0.125-0.25 mg daily if serum creatinine is normal 4
• In elderly patients: 0.0625-0.125 mg daily (occasionally 0.25 mg) 4
• Combination of digoxin and beta-blockade appears superior to either agent alone 4

Treatment Algorithm by NYHA Class

NYHA Class II (Mild Heart Failure)

• ACE inhibitor titrated to target doses 3
• Add beta-blocker and titrate to target doses 3
• Use diuretics as needed during episodes of fluid overload 3

NYHA Class III-IV (Moderate to Severe Heart Failure)

• Diuretics plus ACE inhibitors 3
• Add beta-blockers once stable 3
• Add spironolactone for advanced disease 3
• Refer to specialist care for severe heart failure, unknown etiology, relative contraindications, intolerance to low doses, or previous beta-blocker discontinuation 4

Critical Pitfalls to Avoid

Medication Interactions:

• Direct-acting vasodilators have no specific role in CHF treatment (Class III recommendation) though may be used for concomitant angina or hypertension 4
• Never combine ACE inhibitor, ARB, and mineralocorticoid receptor antagonist due to increased risk of renal dysfunction and hyperkalemia 2
• Avoid diltiazem or verapamil in HFrEF as they increase risk of worsening heart failure 2

Decompensation Management:

• If inotropic support is needed in a patient on beta-blockade, use phosphodiesterase inhibitors as their hemodynamic effects are not antagonized by beta-blockers 4

Contraindications to Beta-Blockers:

• Asthma or severe pulmonary disease 4
• Symptomatic bradycardia or hypotension 3
• Sick sinus syndrome 4

Non-Pharmacological Management

• Educate patients about heart failure pathophysiology, symptom recognition, and self-management 1, 2, 3
• Encourage daily physical activity in stable patients to prevent muscle deconditioning 1, 2, 3
• Control sodium intake, especially in severe heart failure 1, 2, 3
• Avoid excessive fluid intake in severe heart failure 2, 3
• Avoid excessive alcohol consumption 1, 3
• Consider exercise training programs in stable NYHA II-III patients 3