What are the 5 pillars of heart failure management and their examples?

The 5 Pillars of Heart Failure Management

Modern heart failure management is built on four foundational pharmacological pillars—ACE inhibitors/ARBs/ARNIs, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors—with diuretics serving as essential symptomatic therapy, collectively forming the comprehensive treatment approach. 1, 2

The Four Foundational Pillars (Disease-Modifying Therapy)

Pillar 1: ACE Inhibitors/ARBs/ARNIs

• ACE inhibitors are recommended as first-line therapy for all patients with reduced left ventricular systolic function to reduce mortality and morbidity. 3
• Start at low doses and titrate to target doses proven effective in large trials over 2-4 weeks. 3, 2
• Examples include enalapril, lisinopril, or ramipril. 1
• ARNIs (sacubitril/valsartan) are preferred over ACE inhibitors when tolerated for superior mortality reduction. 2
• ARBs serve as alternatives only when ACE inhibitors cause intolerable cough or angioedema. 3

Pillar 2: Beta-Blockers

• Beta-blockers are essential for reducing mortality and hospitalizations in all patients with heart failure and reduced ejection fraction (HFrEF). 1, 2
• Initiate in stable patients on ACE inhibitors and diuretics, starting at low doses with gradual uptitration. 3, 2
• Examples include carvedilol, metoprolol succinate, or bisoprolol. 2
• Continue during hospitalization unless the patient is hemodynamically unstable. 2
• Particularly beneficial post-myocardial infarction with LV systolic dysfunction. 3

Pillar 3: Mineralocorticoid Receptor Antagonists (MRAs)

• Spironolactone or eplerenone is recommended for patients with NYHA class II-IV symptoms and LVEF ≤35% on ACE inhibitors and beta-blockers. 3, 2
• Particularly indicated in patients with recent or current class IV symptoms, preserved renal function, and normal potassium concentration. 3
• Critical monitoring requirement: Check serum potassium and creatinine after 5-7 days, then every 5-7 days until stable to prevent life-threatening hyperkalemia. 3, 2
• Avoid in patients with significant renal impairment (GFR <30 mL/min) or baseline hyperkalemia. 2

Pillar 4: SGLT2 Inhibitors

• SGLT2 inhibitors provide proven mortality benefit in both HFrEF and HFpEF, representing the newest addition to foundational therapy. 1, 2
• Examples include dapagliflozin and empagliflozin. 1
• This class addresses a critical gap by offering effective treatment for heart failure with preserved ejection fraction. 1

The Fifth Essential Component: Diuretics (Symptomatic Management)

Diuretics for Fluid Management

• Diuretics are essential when fluid overload manifests as pulmonary congestion or peripheral edema, providing rapid improvement in dyspnea and exercise tolerance. 3
• Loop diuretics (furosemide, bumetanide, torsemide) are preferred; thiazides can be used if GFR >30 mL/min. 3
• Always administer diuretics in combination with ACE inhibitors, never as monotherapy. 3
• Teach patients flexible diuretic dosing based on daily weight monitoring—increase dose if weight increases >2 kg over 3 days. 1, 2
• For insufficient response: increase dose, combine loop diuretics with thiazides, or administer loop diuretics twice daily. 3
• In severe refractory cases, add metolazone with frequent monitoring of creatinine and electrolytes. 3

Implementation Algorithm

Step 1: Initiate ACE inhibitor (or ARNI if available) at low dose, uptitrate every 2 weeks to target dose. 3, 2

Step 2: Add beta-blocker once ACE inhibitor is stable, starting low and uptitrating gradually. 3, 2

Step 3: Add MRA if NYHA class II-IV with LVEF ≤35% and adequate renal function (GFR >30 mL/min) and potassium <5.0 mEq/L. 3, 2

Step 4: Add SGLT2 inhibitor for additional mortality benefit regardless of diabetes status. 1, 2

Step 5: Use diuretics as needed for congestion, adjusting dose based on symptoms and daily weights. 3, 2

Critical Monitoring Requirements

• Check blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, then every 6 months. 3, 2
• Monitor for hyperkalemia especially when combining ACE inhibitors with MRAs—this is the most common serious adverse effect. 3, 2
• Avoid NSAIDs as they worsen renal function and blunt diuretic response. 3
• Reduce or withhold diuretics for 24 hours before starting ACE inhibitors to minimize hypotension risk. 3

Common Pitfalls to Avoid

• Never use calcium channel blockers (except amlodipine for hypertension) as treatment for heart failure—they worsen outcomes. 3, 2
• Never use long-term intermittent positive inotropic therapy—it increases mortality. 3, 2
• Do not add ARB to the combination of ACE inhibitor plus beta-blocker—increased risk without clear benefit. 3, 2
• Avoid excessive diuresis, which can cause prerenal azotemia and hypotension, limiting ability to uptitrate life-saving medications. 3, 2
• Do not use ARBs instead of ACE inhibitors in patients who have never tried ACE inhibitors—ACE inhibitors are first-line. 3

Additional Therapies for Selected Patients

• Hydralazine plus isosorbide dinitrate for patients intolerant to ACE inhibitors/ARBs due to hypotension or renal insufficiency, particularly beneficial in African American patients. 3, 1
• Digoxin may be added to reduce symptoms and enhance exercise tolerance, especially with atrial fibrillation, but does not reduce mortality. 3, 1
• Exercise training as adjunctive therapy improves clinical status in stable ambulatory patients. 3

Device Therapy Considerations

• ICD for primary prevention in patients with LVEF ≤30-35%, NYHA class II-III on optimal medical therapy ≥3 months, life expectancy >1 year. 2
• Cardiac resynchronization therapy (CRT) with LVEF ≤35%, sinus rhythm, NYHA class II-IV, QRS ≥150 ms with left bundle branch block. 2