What is the recommended workup and treatment for congestive heart failure?

Congestive Heart Failure Workup and Treatment

All patients with suspected heart failure require immediate assessment of left ventricular ejection fraction via echocardiography, followed by rapid initiation of quadruple therapy (ACE inhibitor, beta-blocker, mineralocorticoid receptor antagonist, and SGLT2 inhibitor) in those with reduced ejection fraction to reduce mortality and hospitalization. 1

Diagnostic Workup

Essential Initial Testing

• Obtain B-type natriuretic peptide (BNP) to support the diagnosis, as elevated levels correlate with heart failure severity 2
• Perform echocardiography on all patients with suspected impaired left ventricular ejection fraction to definitively establish the diagnosis and quantify systolic function 2, 3
• Order electrocardiogram and chest X-ray in all patients to identify underlying causes and assess for pulmonary congestion 2
• Measure baseline renal function, electrolytes, and complete blood count before initiating therapy, as these will guide medication dosing and monitoring 4, 1

Identify Underlying Etiology

• Investigate for coronary artery disease and hypertension, as these account for 75-80% of known heart failure cases 2
• Assess for metabolic disorders, infections, infiltrative diseases, and alcohol use, as identifying reversible causes directly impacts treatment strategy 3, 5

Pharmacological Treatment for Heart Failure with Reduced Ejection Fraction (HFrEF)

Foundation: Quadruple Therapy

Initiate all four medication classes simultaneously in stable patients to maximize mortality reduction, rather than sequential addition 1:

1. ACE Inhibitors (First-Line)

• Start with low doses: lisinopril 2.5-5 mg daily, enalapril 2.5 mg twice daily, or ramipril 2.5 mg daily 4, 1, 6
• Titrate to target doses: lisinopril 20-35 mg daily, enalapril 10-20 mg twice daily, or ramipril 5-10 mg daily 1
• Before initiating, reduce or withhold diuretics for 24 hours to minimize hypotension risk 4, 1, 7
• Monitor blood pressure, renal function, and electrolytes at 1-2 weeks after each dose increment, at 3 months, then every 6 months 4, 1, 7
• If renal function deteriorates substantially (creatinine increase >30%), stop treatment 4
• Avoid NSAIDs and potassium-sparing diuretics during initiation to prevent hyperkalemia and renal dysfunction 4, 1

Critical dosing adjustments for renal impairment 6:

• Creatinine clearance >30 mL/min: no adjustment needed
• Creatinine clearance 10-30 mL/min: start with 2.5 mg daily, maximum 40 mg daily
• Hemodialysis or creatinine clearance <10 mL/min: start with 2.5 mg once daily

If ACE inhibitors are not tolerated (typically due to cough), substitute with angiotensin receptor blockers (ARBs), though mortality benefit is less certain 4

2. Beta-Blockers

• Initiate in all stable patients (NYHA class II-IV) already on ACE inhibitors and diuretics to reduce mortality by at least 20% 4, 1, 7
• Use evidence-based agents: bisoprolol, metoprolol succinate CR, carvedilol, or nebivolol 1
• Start with very low doses and double every 1-2 weeks if tolerated 1
• Continue beta-blockers even after acute myocardial infarction in patients with LV systolic dysfunction to reduce mortality 4

3. Mineralocorticoid Receptor Antagonists (MRAs)

• Add spironolactone or eplerenone for patients with NYHA class III-IV symptoms despite ACE inhibitor and beta-blocker therapy 4, 1, 7
• Start with low doses and monitor serum potassium and creatinine after 5-7 days, then recheck every 5-7 days until stable 4, 7
• Avoid the combination of ACE inhibitor, ARB, and MRA due to excessive risk of hyperkalemia and renal dysfunction 1

4. SGLT2 Inhibitors

• Initiate early in all HFrEF patients regardless of diabetes status to reduce cardiovascular death and heart failure hospitalization 1

Diuretic Therapy for Symptom Management

• Use loop diuretics or thiazides in addition to ACE inhibitors for all patients with fluid overload 4, 7
• If GFR <30 mL/min, avoid thiazides except when prescribed 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

Digoxin (Adjunctive Therapy)

• For atrial fibrillation with any degree of heart failure: use digoxin to slow ventricular rate and improve symptoms 4
• For sinus rhythm with persistent symptoms: add digoxin 0.25-0.375 mg daily (0.125-0.25 mg in elderly) to improve clinical status despite ACE inhibitor and diuretic treatment 4
• Contraindications: bradycardia, second- or third-degree AV block, sick sinus syndrome, hypokalaemia, hypercalcaemia 4

Device Therapy

Implantable Cardioverter Defibrillators (ICDs)

• For primary prevention: recommend ICD in symptomatic HF (NYHA class II-III) with LVEF ≤35% despite ≥3 months of optimal medical therapy in patients with ischemic heart disease or dilated cardiomyopathy 1
• For secondary prevention: indicate ICD in patients who survived ventricular arrhythmia causing hemodynamic instability 1

Cardiac Resynchronization Therapy (CRT)

• Recommend CRT for symptomatic heart failure patients in sinus rhythm with QRS duration ≥150 msec, LBBB morphology, and LVEF ≤35% 1

Non-Pharmacological Management

Patient Education and Self-Management

• Provide comprehensive education about heart failure pathophysiology, symptom recognition (dyspnea, fatigue, edema), when to contact healthcare providers, and medication adherence 1, 7
• Teach daily self-weighing to monitor fluid status, with instructions to increase diuretics and alert the team if sudden weight gain occurs 1, 5

Lifestyle Modifications

• Restrict sodium intake to <6 g/day, especially in severe heart failure 4, 1, 5
• Limit fluid intake to 1.5-2 L/day in severe heart failure 1, 5
• Avoid excessive alcohol intake, and mandate complete abstinence in alcohol-induced cardiomyopathy 4, 5
• Encourage daily physical activity in stable patients to prevent muscle deconditioning and improve exercise tolerance 1, 7, 5
• Recommend structured exercise training programs for NYHA class II-III patients 1, 7, 5

Critical Pitfalls to Avoid

• Never use diltiazem or verapamil in HFrEF patients, as they increase risk of heart failure worsening 1
• Do not combine ACE inhibitor, ARB, and MRA due to excessive hyperkalemia and renal dysfunction risk 1
• Avoid excessive diuresis before starting ACE inhibitors, as this increases hypotension risk 4, 1, 7
• Do not discontinue evidence-based medications during hospitalization unless the patient is hemodynamically unstable 5
• In alcohol-induced cardiomyopathy, failure to mandate complete abstinence will result in progressive heart failure and death regardless of medical therapy 5