What is the treatment for low output heart failure?

Treatment of Low Output Heart Failure

For low output heart failure (heart failure with reduced ejection fraction), initiate combination therapy with ACE inhibitors, beta-blockers, SGLT2 inhibitors, and aldosterone antagonists as foundational treatment, with diuretics added for fluid overload, as this quadruple therapy approach maximizes survival and reduces hospitalizations. 1

Immediate Pharmacological Management

First-Line Foundational Therapy (Start Simultaneously)

• ACE Inhibitors: Begin with low doses and titrate to target doses proven effective in clinical trials (e.g., lisinopril 5-40 mg daily), as ACE inhibitors are recommended as first-line therapy for reduced left ventricular systolic function and improve survival 2, 3

  • Start cautiously in patients with low blood pressure; reduce or withhold diuretics for 24 hours before initiation to minimize hypotension risk 2
  • Monitor blood pressure, renal function, and electrolytes 1-2 weeks after initiation and each dose increment 2, 1
  • If ACE inhibitors are not tolerated due to cough or angioedema, substitute with angiotensin receptor blockers (ARBs) such as valsartan 4, 5

• SGLT2 Inhibitors: Initiate dapagliflozin 10 mg daily or empagliflozin 10 mg daily early in treatment, as these agents reduce heart failure hospitalization and mortality with minimal blood pressure impact 1

  • Can be started during hospitalization for acute decompensated heart failure 1
  • Do not start if eGFR <30 mL/min/1.73m² 1

• Mineralocorticoid Receptor Antagonists (MRAs): Add spironolactone 12.5-25 mg daily in NYHA class III-IV patients or those with persistent symptoms, as this reduces sudden death and improves survival 2, 1, 6

  • Only use if eGFR >30 mL/min/1.73m² and potassium <5.0 mEq/L 1, 6
  • Monitor potassium and creatinine closely after 5-7 days and with each dose adjustment 2

• Beta-Blockers: Add bisoprolol, carvedilol, or metoprolol XL/CR and titrate to target doses, as beta-blockers reduce sudden death and improve survival in symptomatic heart failure 2, 4

  • Initiate after hemodynamic stabilization if heart rate >70 bpm 1
  • Start with very low doses and increase gradually 2

Diuretic Therapy for Symptom Relief

• Loop Diuretics: Administer for symptomatic relief when fluid overload manifests as pulmonary congestion or peripheral edema, as diuretics rapidly improve dyspnea and exercise tolerance 2
  • Always combine with ACE inhibitors when possible 2
  • Use cautiously to avoid excessive preload reduction that could further decrease stroke volume and cardiac output 2
  • For insufficient response, increase dose or combine loop diuretics with thiazides 2
  • In severe chronic heart failure with persistent fluid retention, add metolazone with frequent monitoring of creatinine and electrolytes 2

Additional Symptomatic Therapy

• Digoxin: Add low-dose digoxin (targeting serum concentration <1.0 ng/mL) for symptom improvement in patients remaining symptomatic despite optimal therapy 2, 4

  • Cardiac glycosides are often added in NYHA class IV patients 2

• Hydralazine/Isosorbide Dinitrate: Consider this combination in patients who cannot tolerate ACE inhibitors or ARBs due to hypotension or renal dysfunction, particularly in African American patients 2, 4

Management of Low Cardiac Output with Hypotension

Critical Considerations for HF-LBP

• Inotropic Support: For patients with signs/symptoms of hypoperfusion despite optimal oral therapy, temporary inotropic support may be necessary, though current agents increase myocardial oxygen consumption and arrhythmia risk 2, 7, 8

  • Use inotropes cautiously and for the shortest duration possible, as they may worsen outcomes 8

• Hemodynamic Optimization: Address the imbalance between oxygen delivery and oxygen consumption at the cellular level that characterizes low cardiac output syndrome 7

  • Assess and optimize preload, afterload, contractility, and heart rate 7

Nutritional Supplementation

• Thiamine: For patients with high suspicion or proven thiamine deficiency presenting with heart failure, administer 200 mg thiamine three times daily IV, as this improves left ventricular ejection fraction 9
  • For chronic diuretic therapy, provide 50 mg thiamine daily orally as prophylaxis 9
  • Do not delay treatment while awaiting laboratory results 9

Advanced Therapies for Refractory Cases

Escalation for NYHA Class IV

• Cardiac Transplantation: Consider for patients who persist in NYHA class IV despite optimal medical treatment and proper diagnosis 2

• Ventricular Assist Devices: Current indications include bridging to transplantation, transient myocarditis, and in some cases permanent hemodynamic support 2

• Palliative Care: Consider opiates for symptom relief in terminal patients with end-stage heart failure 2

Critical Pitfalls to Avoid

• Do not use diuretics alone for long-term therapy, as they activate the renin-angiotensin-aldosterone system and worsen neurohormonal activation 5

• Avoid calcium antagonists (especially diltiazem and verapamil) in systolic dysfunction, as they worsen outcomes 2, 4

• Avoid Class I antiarrhythmics, as they provoke fatal ventricular arrhythmias and reduce survival 2

• Do not defer SGLT2 inhibitor initiation to outpatient setting, as this exposes patients to excess risk of early post-discharge clinical worsening and death 1

• Do not add ARBs to the combination of ACE inhibitor plus beta-blocker, as this provides no additional benefit and increases adverse effects 2

• Avoid excessive diuresis before ACE inhibitor initiation, as this can cause hypotension and renal dysfunction 2

Monitoring Strategy

• Check blood pressure, renal function, and electrolytes 1-2 weeks after each medication initiation or dose increment, at 3 months, and subsequently at 6-month intervals 2, 1

• Monitor for signs of worsening heart failure including weight gain, increased dyspnea, and peripheral edema 2

• Assess for medication intolerance and adjust therapy accordingly while maintaining as many guideline-directed therapies as possible 1