What is the treatment plan for patients with heart failure?

Treatment Plan for Heart Failure

ACE inhibitors are the cornerstone first-line therapy for all patients with heart failure and reduced left ventricular systolic function, combined with diuretics for symptomatic relief and beta-blockers for mortality reduction. 1, 2

Initial Pharmacological Approach

ACE Inhibitors (First-Line Therapy)

• Start ACE inhibitors immediately in all patients with reduced LV ejection fraction, regardless of symptom severity 1, 2
• Begin with low doses and titrate upward to target maintenance doses proven effective in large trials 1, 2
• Initiate therapy in the evening when supine to minimize hypotensive effects, or if started in the morning, supervise for several hours with blood pressure monitoring 1
• Reduce or withhold diuretics for 24 hours before starting ACE inhibitors to avoid excessive hypotension 1, 2
• Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, and subsequently at 6-month intervals 1, 2
• If renal function deteriorates substantially (creatinine >2 mg/dL), stop treatment 1, 3
• Avoid NSAIDs and potassium-sparing diuretics during ACE inhibitor initiation 1, 2

Diuretics (Essential for Symptomatic Relief)

• Loop diuretics (furosemide) are essential when fluid overload manifests as pulmonary congestion or peripheral edema 1, 4, 2
• Always administer diuretics in combination with ACE inhibitors 1, 2
• Start with standard doses of loop diuretics or thiazides 1, 4
• If GFR <30 mL/min, avoid thiazides except when prescribed synergistically with loop diuretics 1, 2
• For insufficient response: increase diuretic dose, combine loop diuretics with thiazides, or administer loop diuretics twice daily 1, 4
• In severe chronic heart failure with persistent fluid retention, add metolazone with frequent monitoring of creatinine and electrolytes 1, 4

Beta-Blockers (Mortality Reduction)

• Initiate beta-blockers in all stable patients with NYHA class II-IV heart failure and reduced LV ejection fraction who are already on ACE inhibitors and diuretics 1, 2
• Beta-blockers reduce hospitalizations, improve functional class, and prevent worsening heart failure 2
• In patients with LV systolic dysfunction following acute MI, add long-term beta-blockade to ACE inhibition to reduce mortality 1
• Do not use beta-blockers in acute pulmonary edema 4

Aldosterone Receptor Antagonists

• Add spironolactone in advanced heart failure (NYHA class III-IV) on top of ACE inhibitors and diuretics to improve survival 1, 2
• Use potassium-sparing diuretics only if hypokalemia persists after ACE inhibitor and diuretic initiation 1
• Start with 1-week low-dose administration, check serum potassium and creatinine after 5-7 days, and titrate accordingly 1
• Recheck potassium every 5-7 days until values are stable 1, 2

Non-Pharmacological Management

Patient Education and Self-Management

• Explain what heart failure is, why symptoms occur, how to recognize worsening symptoms, and the importance of daily self-weighing 1, 2
• Emphasize strict adherence to both pharmacological and non-pharmacological prescriptions 1, 2
• Advise smoking cessation with nicotine replacement therapies if needed 1

Lifestyle Modifications

• Control sodium intake in patients with severe heart failure and avoid excessive fluid intake 1, 2
• Avoid excessive alcohol consumption 1
• Encourage daily physical activity and leisure activities in stable patients to prevent muscle deconditioning 1, 2
• Rest is not encouraged in stable conditions 1
• Implement exercise training programs in stable NYHA class II-III patients 1

Management of Acute Decompensation

Acute Pulmonary Edema with Hypertension

• Start treatment immediately with oxygen therapy to maintain saturation >90%, followed by CPAP or non-invasive ventilation 4
• Administer intravenous loop diuretics, especially if the patient is clearly volume-overloaded with a long history of chronic heart failure 4
• Give intravenous nitroglycerin or nitroprusside to reduce venous preload and arterial afterload 4
• Consider calcium channel blockers (nicardipine) for patients with diastolic dysfunction and increased afterload 4

Acute Myocardial Infarction with Heart Failure

• Initiate lisinopril 5 mg within 24 hours of symptom onset, followed by 5 mg after 24 hours, then 10 mg daily 3
• For patients with systolic blood pressure <120 mmHg at baseline, reduce initial dose to 2.5 mg 3
• Monitor closely for hypotension (9% incidence) and renal dysfunction (2.4% incidence) 3

Common Pitfalls and Monitoring

Critical Monitoring Parameters

• Hyperkalemia occurs in 2.2% of hypertensive patients and 4.8% of heart failure patients on ACE inhibitors 3
• Monitor for reversible increases in blood urea nitrogen and serum creatinine (occurs in 11.6% of heart failure patients on concomitant diuretics) 3
• Avoid the combination of ACE inhibitors, ARBs, and mineralocorticoid receptor antagonists due to increased risk of renal dysfunction and hyperkalemia 4

Medications to Avoid

• Never use NSAIDs or COX-2 inhibitors as they worsen fluid retention and reduce diuretic effectiveness 1, 4, 2
• Avoid diltiazem or verapamil in patients with heart failure with reduced ejection fraction as they increase risk of worsening heart failure 4
• Avoid class I antiarrhythmic agents, tricyclic antidepressants, and use corticosteroids with extreme caution 5

Treatment Goals and Outcomes

• The primary aims are prevention of disease progression, maintenance or improvement in quality of life, and improved survival 1
• Before discharge, ensure the acute episode has resolved, congestion is absent, and a stable oral diuretic regimen has been established for at least 48 hours 5, 2
• Optimize long-term disease-modifying therapy and provide comprehensive patient and family education 5, 2