What is the treatment plan for patients with heart failure?

Treatment Plan for Heart Failure

ACE inhibitors are the cornerstone first-line therapy for patients with reduced left ventricular systolic function and should be initiated immediately alongside diuretics for symptomatic relief, followed by beta-blockers once the patient is stabilized. 1, 2

Pharmacological Treatment Algorithm

Step 1: Initiate ACE Inhibitors (First-Line)

• Start ACE inhibitors as foundational therapy in all patients with reduced LV ejection fraction, regardless of symptom severity 1, 2
• Begin with a low dose and titrate upward to target maintenance doses proven effective in large clinical trials 1, 2
• Critical initiation protocol: Review current diuretic doses and reduce or withhold diuretics for 24 hours before starting to avoid excessive hypotension 1
• Consider evening dosing when supine to minimize blood pressure drops, though morning initiation with several hours of blood pressure monitoring is also acceptable 1
• Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, and then every 6 months 1, 2
• Stop treatment if renal function deteriorates substantially 1

Step 2: Add Diuretics for Symptomatic Relief

• Loop diuretics (furosemide) or thiazides are essential when fluid overload manifests as pulmonary congestion or peripheral edema 1, 3, 2
• Always administer diuretics in combination with ACE inhibitors, never as monotherapy 1, 2
• If glomerular filtration rate is <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
• In severe chronic heart failure with persistent fluid retention, add metolazone with frequent creatinine and electrolyte monitoring 1, 3

Step 3: Initiate Beta-Blockers (Once Stable)

• Beta-blockers are recommended for all patients with stable mild, moderate, and severe heart failure (NYHA class II-IV) with reduced LV ejection fraction who are already on diuretics and ACE inhibitors 1, 2
• Beta-blockers reduce hospitalizations, improve functional class, and prevent worsening heart failure 2
• In patients with LV systolic dysfunction following acute myocardial infarction, add long-term beta-blockade to ACE inhibition to reduce mortality 1

Step 4: Add Aldosterone Receptor Antagonists for Advanced Disease

• Spironolactone is recommended in advanced heart failure (NYHA class III-IV) in addition to ACE inhibitors and diuretics to improve survival 1, 2
• Use potassium-sparing diuretics only if hypokalemia persists after initiating ACE inhibitors and diuretics 1
• Start with 1-week low-dose administration, check serum potassium and creatinine after 5-7 days, and recheck every 5-7 days until potassium values stabilize 1
• Avoid potassium-sparing diuretics during initial ACE inhibitor therapy 1, 2

Critical Medications to Avoid

• Avoid NSAIDs as they worsen fluid retention and reduce diuretic effectiveness 1, 3
• Avoid the combination of ACE inhibitors, ARBs, and mineralocorticoid receptor antagonists due to increased risk of renal dysfunction and hyperkalemia 3
• Avoid diltiazem or verapamil in patients with heart failure with reduced ejection fraction as they increase risk of worsening heart failure 3
• Avoid beta-blockers in cases of concomitant acute pulmonary edema 3

Non-Pharmacological Management

Patient Education and Self-Management

• Explain what heart failure is, why symptoms occur, how to recognize symptoms, and what to do when symptoms worsen 1, 2
• Teach daily self-weighing to detect early fluid retention 1
• Emphasize importance of medication adherence and smoking cessation with nicotine replacement therapies if needed 1

Lifestyle Modifications

• Encourage daily physical activity and leisure activities in stable patients to prevent muscle deconditioning; rest is not encouraged in stable conditions 1, 2
• Recommend exercise training programs for stable NYHA class II-III patients 1
• Control sodium intake when necessary, especially in severe heart failure 1, 2
• Avoid excessive fluid intake in severe heart failure 1, 2
• Avoid excessive alcohol intake 1

Special Clinical Scenarios

Acute Myocardial Infarction with Heart Failure

• In hemodynamically-stable patients presenting within 24 hours of MI onset, start lisinopril 5 mg within 24 hours, 5 mg after 24 hours, then 10 mg daily 4
• Patients with systolic blood pressure <120 mmHg at baseline should receive 2.5 mg of lisinopril 4
• Reduce dose if hypotension occurs; stop if severe hypotension develops 4

Acute Pulmonary Edema with Hypertension

• Start treatment immediately: oxygen therapy, CPAP or non-invasive ventilation, and if necessary, short-term invasive mechanical ventilation 3
• Maintain oxygen saturation above 90% at all times 3
• Administer intravenous loop diuretics, especially if clearly volume-overloaded with long history of chronic heart failure 3
• Give nitroglycerin or nitroprusside intravenously to reduce venous preload and arterial afterload 3
• Consider calcium channel blocker (nicardipine) since these patients usually have diastolic dysfunction with increased afterload 3

Common Pitfalls and How to Avoid Them

• Pitfall: Starting ACE inhibitors without adjusting diuretics leads to severe hypotension 1

  • Solution: Reduce or withhold diuretics for 24 hours before ACE inhibitor initiation 1, 2

• Pitfall: Using diuretics as monotherapy without ACE inhibitors misses mortality benefit 1, 2

  • Solution: Always combine diuretics with ACE inhibitors 1, 2

• Pitfall: Adding potassium-sparing diuretics too early causes dangerous hyperkalemia 1

  • Solution: Avoid during ACE inhibitor initiation; only add if hypokalemia persists 1, 2

• Pitfall: Inadequate monitoring of renal function and electrolytes leads to preventable complications 1, 2

  • Solution: Check blood pressure, renal function, and electrolytes 1-2 weeks after each dose change, at 3 months, then every 6 months 1, 2