What are the four pillars of congestive heart failure?

Four Pillars of Congestive Heart Failure Treatment

The four pillars of modern heart failure with reduced ejection fraction (HFrEF) management are ACE inhibitors (or ARBs/ARNI), beta-blockers, mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors—this "quadruple therapy" forms the foundation of evidence-based treatment for symptomatic HFrEF. 1, 2

The Four Pillars Explained

1. ACE Inhibitors (or ARB/ARNI Alternatives)

• ACE inhibitors are first-line therapy for all patients with reduced left ventricular systolic function, regardless of symptom severity, as they reduce mortality and prevent progression to symptomatic heart failure 1, 2
• Start with low doses and titrate upward to the maintenance dosages proven effective in large clinical trials 3
• Angiotensin receptor blockers (ARBs) serve as alternatives for patients who cannot tolerate ACE inhibitors (typically due to cough), though their mortality benefit may not be as robust 3, 1
• Sacubitril/valsartan (ARNI) is recommended as a replacement for ACE inhibitors in ambulatory patients with HFrEF who remain symptomatic despite optimal treatment, with high-quality evidence supporting this approach 1

2. Beta-Blockers

• Beta-blockers should be used in all stable patients with mild, moderate, and severe heart failure (NYHA class II-IV) with reduced ejection fraction, in addition to ACE inhibitors and diuretics 3, 1
• These agents prevent symptomatic heart failure and reduce mortality in patients with left ventricular systolic dysfunction 4, 2
• Initiate at low doses with slow titration, as patients may initially experience symptom worsening before improvement occurs 3
• In post-myocardial infarction patients with reduced ejection fraction, long-term beta-blockade is essential in addition to ACE inhibition 3

3. Mineralocorticoid Receptor Antagonists (MRAs)

• Aldosterone antagonists like spironolactone are recommended for patients with NYHA class II-IV heart failure and ejection fraction ≤35% who remain symptomatic despite ACE inhibitor and beta-blocker therapy 3, 4, 1
• These agents improve both survival and morbidity in advanced heart failure 3
• Critical monitoring for hyperkalemia and renal insufficiency is mandatory, with potassium and creatinine checks 5-7 days after initiation and dose adjustments 3, 4
• Avoid combining MRAs with both ACE inhibitors and ARBs simultaneously due to excessive risk of renal dysfunction and hyperkalemia 1

4. SGLT2 Inhibitors (Newest Pillar)

• SGLT2 inhibitors now represent the fourth pillar of quadruple therapy for HFrEF, completing the modern evidence-based foundation 2
• This class has emerged as essential therapy based on recent high-quality evidence demonstrating mortality and hospitalization benefits 2

Essential Adjunctive Therapy: Diuretics

While not traditionally counted among the "pillars," diuretics are essential for symptomatic treatment when fluid overload is present and should always be administered in combination with ACE inhibitors 1

• Loop diuretics or thiazides form the basis of initial diuretic treatment 3
• If glomerular filtration rate is <30 mL/min, avoid thiazides except when prescribed synergistically with loop diuretics 3
• For insufficient response, increase the diuretic dose, combine loop diuretics with thiazides, or administer loop diuretics twice daily 3
• Meticulous control of fluid retention is critical, particularly in end-stage heart failure 4

Additional Evidence-Based Therapies

Cardiac Glycosides (Digoxin)

• Digoxin is recommended for patients with persistent heart failure symptoms despite ACE inhibitor and diuretic treatment, or for rate control in atrial fibrillation 3, 1
• The usual daily dose is 0.25-0.375 mg if renal function is normal, with lower doses (0.125-0.25 mg) in elderly patients 3
• Combination of digoxin and beta-blockade appears superior to either agent alone 3

Critical Implementation Principles

Initiation and Titration

• Start all neurohormonal antagonists at low doses and build up gradually to target doses proven in clinical trials 3, 1
• When initiating ACE inhibitors, review and potentially reduce diuretic doses to avoid excessive hypotension 3, 4
• Consider starting ACE inhibitors in the evening when supine to minimize blood pressure effects, though evidence specific to heart failure is limited 3

Monitoring Requirements

• Check blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, and subsequently at 6-month intervals 3
• Monitor for signs of worsening congestion or hypoperfusion at each visit 3, 2
• Patients should be educated on daily weight monitoring and instructed to report weight gains >2 kg in 3 days 1

Common Pitfalls to Avoid

• Avoid NSAIDs in all heart failure patients, as they worsen fluid retention and reduce the effectiveness of ACE inhibitors 3
• Never use diltiazem or verapamil in patients with HFrEF, as these calcium channel blockers increase the risk of heart failure worsening 1
• Avoid potassium-sparing diuretics during initial ACE inhibitor therapy to prevent dangerous hyperkalemia 3
• Do not undertitrate medications—failure to reach target doses is a common error that reduces treatment effectiveness 1
• Before classifying a patient as having refractory heart failure, confirm diagnostic accuracy, identify reversible factors, and ensure all conventional therapies have been optimally employed 4