From the Guidelines
For patients with heart failure, the most effective treatment approach is to use ACE inhibitors and beta blockers in all patients with stage B or C heart failure who have a reduced ejection fraction, as recommended by the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) guidelines 1. This approach is based on the understanding that heart failure is a complex clinical syndrome that results from structural or functional impairment of ventricular filling or ejection of blood. The guidelines emphasize the importance of modifying risk factors, treating structural heart disease, and reducing morbidity and mortality at each stage of heart failure. Key points for practice include:
- Treatment of stage A heart failure should focus on reducing modifiable risk factors, including management of hypertension and hyperlipidemia.
- Patients with stage C heart failure and fluid retention should be treated with diuretics in addition to ACE inhibitors and beta blockers.
- The diagnosis of heart failure requires a careful history and physical examination, and may involve the use of diagnostic tests such as echocardiography and biomarkers. The use of ACE inhibitors and beta blockers has been shown to improve cardiac function, reduce symptoms, and decrease mortality in patients with heart failure, and should be initiated at low doses and gradually uptitrated as tolerated 1. It is also important to note that heart failure is not equivalent to cardiomyopathy or to LV dysfunction, but rather a clinical syndrome that is characterized by specific symptoms and signs 1. Additionally, the European Society of Cardiology guidelines emphasize the importance of diagnosing and treating heart failure with preserved ejection fraction (HF-PEF) and heart failure with reduced ejection fraction (HF-REF) separately, as they may require different treatment strategies 1. Overall, a comprehensive approach to heart failure management should include the use of ACE inhibitors, beta blockers, and other evidence-based therapies, as well as careful monitoring and follow-up to optimize patient outcomes.
From the Research
Treatment Options for Heart Failure
- The initial therapy for heart failure should consist of pharmacologic agents to relieve symptoms and prevent ventricular remodeling, as stated in the study 2.
- ACE inhibitors, along with digitalis and diuretics, have been shown to improve exercise tolerance and decrease treatment failure in symptomatic patients 2.
- Angiotensin II receptor blockers (ARBs) may be used as an alternative to ACE inhibitors, but they do not provide a survival benefit 2.
- The use of beta-blockers, such as ss-adrenoceptor antagonists, has been associated with improved ventricular function and survival in patients with symptomatic systolic left ventricular failure 2.
Importance of Continuing Therapy
- Continuing or initiating angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEi/ARB) in hospitalized patients with heart failure with reduced ejection fraction is crucial, as discontinuation is associated with higher rates of postdischarge mortality and readmission 3.
- Patients who are continued or started on ACEi/ARB therapy have lower 30-day mortality and readmission rates compared to those who are discontinued or not started on therapy 3.
Current Guidelines and Recommendations
- Optimal guideline-directed medical therapy for heart failure with reduced ejection fraction includes the use of sacubitril/valsartan, an evidence-based beta-blocker, a mineralocorticoid antagonist, and a sodium-glucose cotransporter-2 inhibitor 4.
- For heart failure with preserved ejection fraction, optimal therapy includes a sodium-glucose cotransporter-2 inhibitor, with emerging evidence supporting the use of mineralocorticoid antagonists and glucagon-like peptide-1 receptor agonists 4.
- Evidence-based management of acute heart failure involves considering the mechanisms of decompensation, precipitating factors, and end-organ manifestations to select appropriate therapies 5.