What is the recommended treatment for patients with heart failure and acute coronary syndrome (ACS)?

Management of Heart Failure with Acute Coronary Syndrome

For patients presenting with both heart failure and acute coronary syndrome, immediate invasive coronary angiography is recommended regardless of electrocardiographic or biomarker findings, while simultaneously initiating guideline-directed medical therapy for both conditions with priority given to time-sensitive interventions. 1

Immediate Diagnostic and Invasive Management

Urgent Evaluation

• Obtain immediate ECG and echocardiography in all patients with suspected cardiogenic shock or acute heart failure with ACS 2
• Measure plasma natriuretic peptides (BNP, NT-proBNP, or MR-proANP) to confirm acute heart failure and differentiate from non-cardiac causes of dyspnea 2
• Recognize that cardiac biomarkers are frequently elevated in acute heart failure independently of ACS, making diagnosis challenging 1

Invasive Strategy

• Transfer immediately to a tertiary care center with 24/7 cardiac catheterization capability if cardiogenic shock is present 2
• Proceed with coronary angiography in all ACS patients with heart failure, as this combination carries substantially higher short-term mortality risk than ACS alone 1, 3
• Note that in real-world practice, only 66% of ACS patients with heart failure receive angiography, representing a critical treatment gap 3

Acute Pharmacological Management

Diuretic Therapy for Congestion

• Administer intravenous furosemide 20-40 mg (or equivalent) for new-onset acute heart failure or patients not on chronic diuretics 2
• For patients already on oral diuretics, give initial IV dose at least equivalent to their oral dose 2
• Administer as intermittent boluses or continuous infusion, titrating based on symptoms and clinical status 2
• Monitor urine output, renal function, and electrolytes regularly during IV diuretic use 2

Vasodilator Therapy

• Initiate intravenous nitrates as first-line therapy if blood pressure is adequate and signs of congestion are present 2
• Start with glyceryl trinitrate 20 mcg/min, increasing to 200 mcg/min, or isosorbide dinitrate 1-10 mg/h, titrating carefully against blood pressure 2
• Nitrates are particularly effective in ACS with heart failure, relieving pulmonary congestion without compromising stroke volume 2
• Titrate to the highest hemodynamically tolerable dose, as suboptimal dosing limits effectiveness 2
• Be aware that tolerance develops rapidly (16-24 hours) with high-dose IV nitrates 2

Inotropic Support - Use Sparingly

• Avoid inotropic agents unless the patient is symptomatically hypotensive or hypoperfused, as they increase mortality risk 2

Morphine for Symptom Relief

• Consider morphine 3 mg IV bolus in early treatment if severe dyspnea and restlessness are present, repeatable as needed 2

Chronic Heart Failure Medical Therapy - The Four Pillars

Foundation Therapy Initiation

Continue or initiate all four foundational medication classes as soon as hemodynamically stable, even during the acute hospitalization for ACS 4:

1. ACE inhibitor (or ARB if intolerant): Start enalapril 2.5 mg twice daily or lisinopril 5 mg daily 4, 5
2. Beta-blocker: Initiate carvedilol, bisoprolol, or metoprolol succinate at low doses 4, 6
3. Mineralocorticoid receptor antagonist (MRA): Add for symptomatic patients 4
4. SGLT2 inhibitor: Initiate as part of foundational therapy 4

Critical Principle During Acute Phase

• Make every attempt to continue evidence-based disease-modifying therapies during acute decompensation, unless hemodynamic instability or contraindications exist 2
• This is a common pitfall: clinicians often discontinue these life-saving medications during acute illness when they should be maintained 2

Titration Strategy Post-Discharge

Beta-Blocker Optimization

• Titrate beta-blockers every 2 weeks to target doses: carvedilol 25 mg twice daily, bisoprolol 10 mg daily, or metoprolol succinate 200 mg daily 4, 6
• This is critical because real-world data show only 17.5% of patients reach target carvedilol doses and 7.9% reach target metoprolol doses, representing a major treatment gap 7
• Higher beta-blocker doses are associated with better clinical outcomes, so aggressive titration is essential 6

ACE Inhibitor Titration

• Titrate ACE inhibitors every 2 weeks to target doses: enalapril 10 mg twice daily or lisinopril 20-35 mg daily 4, 5
• Monitor renal function and electrolytes 1-2 weeks after initiation and with each dose increase 5

Advanced Therapy for Persistent Symptoms

• Replace ACE inhibitor with sacubitril/valsartan if patient remains symptomatic despite optimal doses of ACE inhibitor, beta-blocker, and MRA 2, 4
• This further reduces heart failure hospitalization and death risk 4

Managing Treatment Barriers

Hypotension Management

• Reduce diuretic dose first rather than reducing guideline-directed medical therapy, as asymptomatic hypotension is expected and beneficial with optimal therapy 4
• Do not discontinue beta-blockers or ARNI for asymptomatic hypotension 4

Hyperkalemia Management

• Adjust MRA dose and use potassium binders rather than discontinuing ARNI or beta-blocker 4
• This allows continuation of life-saving therapy 4

Critical Medications to Avoid

• Do not use NSAIDs or COX-2 inhibitors, as they increase heart failure worsening and hospitalization risk 2
• Do not use thiazolidinediones (glitazones), as they worsen heart failure 2
• Do not combine ACE inhibitors with ARBs or renin inhibitors, as this increases renal dysfunction and hyperkalemia risk 5

Long-Term Monitoring and Outcomes

• Enroll patients in multidisciplinary care management programs to reduce heart failure hospitalization and mortality 2
• Encourage regular aerobic exercise in stable patients to improve functional capacity and reduce hospitalization risk 2
• Recognize that nearly half of ACS patients presenting with heart failure die within four years, emphasizing the need for aggressive optimal medical therapy 3
• Real-world data show that quadruple therapy rates fall from 61% at discharge to 45% at one year in this population, representing a critical quality gap to address 3