Heart Failure: A Practical Guide for General Practitioners
Understanding Heart Failure Pathophysiology
Heart failure is fundamentally a neurohormonal disease where the heart's inability to pump adequate blood triggers compensatory mechanisms (RAAS activation, sympathetic overdrive) that initially maintain cardiac output but ultimately accelerate cardiac remodeling, fluid retention, and progressive myocardial dysfunction. 1
Key Pathophysiologic Concepts
- Neurohormonal activation drives disease progression through angiotensin II, aldosterone, and norepinephrine, causing vasoconstriction, sodium retention, and myocardial fibrosis 1, 2
- Cardiac remodeling occurs as the ventricle dilates and wall stress increases, perpetuating the cycle of dysfunction 2
- Endothelial dysfunction and chronic inflammation contribute to peripheral symptoms and exercise intolerance 2, 3
- The disease progresses silently even when patients appear clinically stable—most hospitalizations and deaths occur in NYHA class II-III patients who seem "stable" 2
Diagnosis: A Systematic Approach
Initial Suspicion and Testing
When you suspect heart failure based on dyspnea, fatigue, or edema, immediately order an ECG and BNP/NT-proBNP before referring to cardiology—this accelerates diagnosis and is the recommended pathway. 4
Essential Diagnostic Steps:
- ECG: Abnormal in >90% of HF cases; a normal ECG makes HF unlikely 4
- BNP/NT-proBNP: Critical screening tool; elevated levels support diagnosis and guide referral urgency 4, 1
- Echocardiography: Definitive test to confirm diagnosis, assess ejection fraction, and evaluate valve disease 4, 1
- Routine labs: Complete blood count, comprehensive metabolic panel, liver function tests, thyroid function 4
Classification That Drives Treatment
Classify patients as HFrEF (EF ≤40%) or HFpEF (EF ≥50%) immediately—this distinction fundamentally changes your pharmacologic approach. 1
- HFrEF has robust evidence for mortality-reducing therapies 1
- HFpEF management focuses primarily on symptom control and comorbidity management 1
- NYHA functional class (I-IV) guides therapy intensity and prognosis 1
Management: The Pharmacologic Foundation
First-Line Therapy for HFrEF
Start ACE inhibitors immediately in all HFrEF patients unless contraindicated—they reduce mortality and are the cornerstone of therapy. 1, 5, 6
ACE Inhibitor Initiation Protocol:
- Begin with low doses (e.g., enalapril 2.5 mg BID, lisinopril 2.5-5 mg daily) 1, 5
- Uptitrate every 1-2 weeks to target doses proven in trials (enalapril 10 mg BID, lisinopril 20-40 mg daily) 1, 5
- Monitor blood pressure, creatinine, and potassium 1-2 weeks after each dose increase 5
- Avoid potassium-sparing diuretics during ACE inhibitor initiation 5
- If ACE inhibitor intolerant (cough, angioedema), switch to ARB 1, 6
Add Beta-Blockers for All Stable Patients
Beta-blockers must be added to ACE inhibitors in all stable NYHA class II-IV patients—they independently reduce mortality and hospitalizations. 1, 6
- Use evidence-based agents: carvedilol, metoprolol succinate, or bisoprolol 1
- Start at very low doses when euvolemic and stable 1
- Uptitrate slowly every 2-4 weeks to maximum tolerated or target doses 1
- Never stop abruptly even during decompensation—reduce dose if necessary 1
Diuretics: Essential for Symptom Control
Loop diuretics (furosemide, bumetanide, torsemide) are mandatory when fluid overload is present—always combine with ACE inhibitors, never use alone. 1, 5, 7
Diuretic Management Strategy:
- Start with standard doses and increase progressively if response inadequate 5
- Double the dose up to furosemide 500 mg equivalent if no initial response 7
- For persistent fluid retention, add thiazides or metolazone with frequent creatinine/electrolyte monitoring 5
- Avoid excessive diuresis in right heart failure—can compromise RV filling 7
Mineralocorticoid Receptor Antagonists
Add spironolactone or eplerenone in patients who remain symptomatic despite ACE inhibitor and beta-blocker—they provide additional mortality benefit in NYHA class III-IV. 1, 6
- Monitor potassium and creatinine closely 1
- Never combine ACE inhibitor + ARB + MRA due to hyperkalemia and renal dysfunction risk 1, 5
Advanced Therapy: Sacubitril/Valsartan
Replace ACE inhibitors with sacubitril/valsartan (ARNI) in ambulatory HFrEF patients who remain symptomatic on optimal therapy—it provides superior mortality reduction compared to enalapril. 1, 2
- This is a Class I recommendation with high-quality evidence 1
- Requires 36-hour washout from ACE inhibitors before initiation 2
- Represents the new standard of care for HFrEF 2
Ivabradine for Persistent Tachycardia
Consider ivabradine in patients with HFrEF, sinus rhythm, heart rate ≥70 bpm despite maximally tolerated beta-blocker—it reduces heart failure hospitalizations. 8, 2
- Dose: Start 5 mg BID, titrate to 7.5 mg BID targeting heart rate 50-60 bpm 8
- Proven benefit in the SHIFT trial with 18% reduction in primary endpoint 8
- Particularly useful when beta-blockers cannot be uptitrated due to hypotension or fatigue 8
Device Therapy: Know When to Refer
ICD Indications
Refer for ICD evaluation in HFrEF patients with LVEF ≤35% who remain NYHA class II-III despite ≥3 months optimal medical therapy—this is a Class I indication for primary prevention. 1
- Also indicated for secondary prevention after hemodynamically unstable ventricular arrhythmia 1
Cardiac Resynchronization Therapy
Refer for CRT in symptomatic HF patients with LVEF ≤35%, sinus rhythm, QRS ≥150 msec with LBBB morphology—this improves symptoms and reduces mortality. 1
- CRT-D (with defibrillator) preferred over CRT-P (pacing only) in most cases 4
- Requires specialized HF clinic for optimal device programming and follow-up 4
Lifestyle Modifications: Evidence-Based Recommendations
Sodium and Fluid Management
Advise moderate sodium restriction (2-3 g/day) in symptomatic patients, but avoid overly strict restriction (<2 g/day) which may be harmful. 1, 9
- Excessive fluid restriction should be avoided except in severe HF 1
- Daily weighing is critical—instruct patients to report weight gain >2 kg in 3 days 1
Exercise and Physical Activity
Encourage daily physical activity and cardiac rehabilitation in stable patients—exercise improves functional capacity and quality of life without increasing risk. 1, 3, 9
- Avoid strict bed rest which causes deconditioning 1
- Cardiac rehabilitation programs reduce hospitalizations 3
Smoking and Alcohol
Smoking cessation is mandatory—counsel at every visit. 1, 9
Alcohol should be limited or avoided entirely, particularly in patients with alcohol-induced cardiomyopathy. 1, 9
Dietary Patterns
The DASH diet shows clear benefit in HF patients, while Mediterranean diet evidence is insufficient—recommend DASH specifically. 9
Critical Medications to AVOID
Dangerous Drug Classes in HFrEF
Never prescribe diltiazem or verapamil in HFrEF—they increase heart failure worsening and mortality. 1, 5
Avoid NSAIDs and COX-2 inhibitors—they worsen fluid retention, reduce diuretic effectiveness, and increase hospitalization risk. 5, 7
Do not use class I antiarrhythmics except amiodarone for severe symptomatic ventricular tachycardia. 7
Avoid triple neurohormonal blockade (ACE inhibitor + ARB + MRA)—this causes dangerous hyperkalemia and renal dysfunction. 1, 5
Managing Acute Decompensation
Immediate Actions for Acute Pulmonary Edema
Start oxygen immediately to maintain saturation >90%, initiate IV loop diuretics, and give IV nitroglycerin or nitroprusside for preload/afterload reduction—do NOT give beta-blockers acutely. 5
- CPAP or non-invasive ventilation if respiratory distress persists 5
- Avoid beta-blockers during acute pulmonary edema 5
- Consider IV inotropes (dobutamine 2.5-5 μg/kg/min) if hypoperfusion present 7
Referral Strategy and Multidisciplinary Care
When to Refer to Cardiology
Refer all suspected HF patients to cardiology after obtaining ECG and BNP—ideally to a specialized HF clinic for diagnostic confirmation and treatment initiation. 4
Refer high-risk patients to multidisciplinary HF disease management programs—these reduce hospitalizations and improve outcomes. 1
Follow-Up After Hospitalization
Schedule follow-up within 7 days of hospital discharge—early post-discharge visits reduce readmissions. 1
Ensure patients are euvolemic, on stable oral diuretic regimen for ≥48 hours, and have optimized disease-modifying therapy before discharge. 7
Common Pitfalls to Avoid
Inadequate uptitration of medications to target doses is the most common error—most patients never reach evidence-based doses that reduce mortality. 1, 2
Failure to educate patients about daily weighing, symptom recognition, and medication adherence leads to preventable hospitalizations. 1
Stopping beta-blockers during mild decompensation worsens outcomes—reduce dose instead of discontinuing. 1
Treating HFpEF the same as HFrEF—remember that mortality-reducing drugs proven in HFrEF lack evidence in HFpEF. 1
Neglecting to address the "stable" NYHA class II-III patient—these patients have progressive disease and account for most deaths. 2