What are the management strategies for heart failure?

Management of Heart Failure

Heart failure management requires a staged, algorithmic approach centered on four foundational pharmacological therapies (ACE inhibitors/ARBs/ARNIs, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors) combined with diuretics for symptom control, supported by structured non-pharmacological interventions and multidisciplinary follow-up. 1, 2

Initial Assessment and Risk Stratification

Determine heart failure phenotype immediately:

• HFrEF (EF ≤40%): Requires all four foundational therapies 1
• HFpEF (EF ≥50%): SGLT2 inhibitors are the primary disease-modifying therapy 2
• HFmrEF (EF 41-49%): Treat similarly to HFrEF with SGLT2 inhibitors 3

Apply ACC/AHA staging to guide treatment intensity: 2, 4

• Stage A (at risk, no structural disease): Control hypertension to BP <130/80 mmHg if cardiovascular risk >10%, treat hyperlipidemia, consider ACE inhibitors/ARBs 4
• Stage B (structural disease, no symptoms): Initiate ACE inhibitors/ARBs AND beta-blockers in all patients with reduced EF 4
• Stage C (structural disease with current/prior symptoms): Deploy all four foundational therapies plus diuretics 2
• Stage D (refractory symptoms): Consider mechanical circulatory support, transplantation, or palliative care 2

Assess NYHA functional class at every visit to guide medication titration and determine need for advanced therapies 1

Core Pharmacological Management for HFrEF

The Four Foundational Therapies (Start All Simultaneously When Possible)

ACE Inhibitors/ARBs/ARNIs:

• Start enalapril 2.5-5 mg twice daily, uptitrate to target 10-20 mg twice daily over 2-4 weeks 4
• Reduce mortality and hospitalization in all symptomatic patients with LVEF ≤40% 4
• If ACE inhibitor intolerant due to cough, switch to ARB 2
• Consider ARNI (sacubitril/valsartan) for superior outcomes in ambulatory patients 2

Beta-Blockers:

• Essential for reducing mortality and hospitalizations when added to ACE inhibitors 2, 4
• Continue during hospitalization unless hemodynamically unstable 4
• Uptitrate to target doses proven in clinical trials 1

Mineralocorticoid Receptor Antagonists (MRAs):

• Indicated for patients with recent or current NYHA Class IV symptoms 2, 4
• Monitor potassium and renal function closely after initiation and dose changes 2
• Reduce mortality in advanced symptomatic HF 4

SGLT2 Inhibitors:

• Provide mortality benefit in both HFrEF and HFpEF 2, 4
• Should be initiated as part of foundational therapy regardless of diabetes status 3
• Represent the newest addition to core therapy with robust evidence 2

Symptomatic Management

Diuretics:

• Essential for fluid overload; titrate dose based on symptoms and volume status 1, 2
• For acute decompensation, administer IV loop diuretics at doses equal to or exceeding chronic oral daily dose within 1 hour of presentation 4
• Teach patients flexible diuretic regimen based on daily weight monitoring 5

Alternative and Adjunctive Therapies

Hydralazine plus Isosorbide Dinitrate:

• For patients intolerant to ACE inhibitors/ARBs due to hypotension or renal insufficiency 2
• Particularly beneficial in African American patients 2

Digoxin:

• May reduce symptoms and enhance exercise tolerance 2
• Monitor for toxicity, especially with renal impairment 2
• Does not improve mortality but reduces hospitalizations 6

Exercise Training:

• Improves functional capacity and quality of life in stable ambulatory patients (NYHA Class I-III) 4
• Recommended as adjunctive therapy 2

Device Therapy for Selected Patients

Implantable Cardioverter-Defibrillator (ICD):

• Primary prevention in patients with LVEF ≤30-35%, NYHA Class II-III on optimal medical therapy ≥3 months, and life expectancy >1 year 4

Cardiac Resynchronization Therapy (CRT):

• Indicated with LVEF ≤35%, sinus rhythm, NYHA Class II-IV, and QRS ≥150 ms with left bundle branch block morphology 4

Non-Pharmacological Management

Patient Education (Critical for Reducing Readmissions):

• Teach symptom recognition and self-monitoring techniques 1
• Explain medication adherence importance and lifestyle modifications 1
• Instruct patients to weigh daily at the same time and report weight gain >2 kg in 3 days 1, 4

Dietary Modifications:

• Restrict sodium intake to <2-3 g/day 4
• DASH diet shows clear benefit 7
• Mediterranean diet lacks sufficient evidence currently 7

Lifestyle Interventions:

• Smoking cessation is mandatory 1
• Limit alcohol intake 1
• Regular physical activity improves outcomes 1, 8

Structured Follow-Up and Transitional Care

Multidisciplinary Disease Management Programs:

• Refer high-risk patients to structured HF programs 1
• Use team-based approach with HF nurse specialists 5
• Improves quality of life, reduces readmissions, and decreases costs 5

Post-Discharge Protocol:

• Schedule early follow-up within 7 days of hospital discharge 1, 2
• Telephone follow-up within 3 days 2
• Provide patient-centered discharge instructions with clear transitional care plan 1
• First follow-up within 10 days of discharge for optimal outcomes 5

Monitoring Parameters at Each Visit:

• Symptoms, weight, blood pressure, heart rate, volume status 4
• Renal function and electrolytes, especially after medication changes 2, 4
• Consider serial natriuretic peptides (BNP or NT-proBNP) to guide therapy and assess prognosis 4

Management of Acute Decompensation

Initial 24-Hour Management:

• Continuous monitoring of heart rate, rhythm, blood pressure, and oxygen saturation 1
• Maintain oxygen saturation above 90% 1
• Assess volume status immediately to guide diuretic dosing 2

Inotropic Support:

• Consider dobutamine or milrinone for patients with low cardiac output 1
• Use cautiously as they do not improve long-term outcomes 9

Medication Continuation:

• Continue ACE inhibitors and beta-blockers during hospitalization unless hemodynamically unstable 4
• Avoid stopping foundational therapies unnecessarily 2

Management of HFpEF

Primary Therapy:

• SGLT2 inhibitors are the only disease-modifying therapy with proven mortality benefit 2
• Diuretics for symptomatic fluid overload 1

Aggressive Comorbidity Management:

• Control hypertension, treat atrial fibrillation, manage diabetes 3
• These interventions are more critical in HFpEF than in HFrEF 3

Common Pitfalls to Avoid

Medication-Related Errors:

• Inadequate uptitration to target doses proven in clinical trials 1
• Premature discontinuation of beta-blockers during acute decompensation 4
• Failure to initiate all four foundational therapies in eligible HFrEF patients 2

Clinical Management Errors:

• Inadequate diuresis in volume-overloaded patients 1
• Neglecting patient education and self-care strategies 1
• Inadequate transitional care planning leading to early readmissions 1

Monitoring Failures:

• Not monitoring renal function and electrolytes after MRA initiation 2
• Failing to assess volume status at each visit 4

Therapies NOT Recommended

Avoid the following interventions: 2

• Long-term intermittent positive inotropic drugs
• Calcium channel blockers for HF treatment
• Routine nutritional supplements
• Hormonal therapies

Special Populations

Atrial Fibrillation with HF:

• Consider amiodarone to convert to sinus rhythm and improve cardioversion success 5
• Rate control is acceptable if rhythm control fails 5

Post-Myocardial Infarction:

• Initiate lisinopril 5 mg within 24 hours of symptom onset, then 5 mg after 24 hours, then 10 mg daily 10
• Reduce dose to 2.5 mg if systolic BP <120 mmHg at baseline 10
• Lisinopril reduces 6-week mortality by 11% in hemodynamically stable post-MI patients 10

Advanced/Refractory HF (Stage D):

• Evaluate for mechanical circulatory support or heart transplantation in eligible patients 2
• Initiate palliative care to improve quality of life 2