What are the treatment options for acute on chronic congestive heart failure (CHF)?

From the Guidelines

Acute on chronic congestive heart failure (CHF) should be managed with diuretics, such as furosemide 20-40mg IV, as the initial treatment to reduce fluid overload, as recommended by the 2016 ESC guidelines 1. The management of acute on chronic CHF involves several key components, including:

• Diuretics: The initial recommended dose of furosemide should be 20-40mg IV, which can be increased as needed, and the dose and duration should be adjusted according to the patient's symptoms and clinical status 1.
• Oxygen therapy: Should be provided to maintain saturation above 92% 1.
• ACE inhibitors or ARBs: Should be continued or initiated once the patient is stable, with medications such as lisinopril 5-40mg daily or losartan 25-100mg daily 1.
• Beta-blockers: Should be maintained if possible, but may need temporary reduction during acute episodes, with medications such as metoprolol succinate 12.5-200mg daily or carvedilol 3.125-25mg twice daily 1.
• Inotropic support: May be necessary for severe cases, with medications such as dobutamine 2.5-10 mcg/kg/min or milrinone 1.
• Addressing precipitating factors: Is crucial, including treating infections with appropriate antibiotics, addressing medication non-adherence, and controlling arrhythmias 1.
• Close follow-up: Is necessary, with daily weight monitoring, salt restriction (<2g sodium/day), and fluid restriction (1.5-2L/day) 1. The 2019 ACC/AHA guidelines comparison with ESC guidelines on heart failure also supports the use of diuretics, ACE inhibitors, ARBs, beta-blockers, and mineralocorticoid receptor antagonists in the management of heart failure 1. Overall, the management of acute on chronic CHF requires a comprehensive approach that addresses both the immediate fluid overload and the underlying neurohormonal activation, with a focus on reducing morbidity, mortality, and improving quality of life.

From the FDA Drug Label

The primary objective of PARADIGM-HF was to determine whether sacubitril and valsartan, a combination of sacubitril and an RAS inhibitor (valsartan), was superior to an RAS inhibitor (enalapril) alone in reducing the risk of the combined endpoint of cardiovascular (CV) death or hospitalization for heart failure (HF) Patients had to have been on an ACE inhibitor or ARB for at least four weeks and on maximally tolerated doses of beta-blockers. The population was 66% Caucasian, 18% Asian, and 5% Black; the mean age was 64 years and 78% were male. At randomization, 70% of patients were NYHA Class II, 24% were NYHA Class III, and 0. 7% were NYHA Class IV.

The sacubitril and valsartan combination is used for the treatment of heart failure. The PARADIGM-HF study demonstrated that this combination is superior to enalapril in reducing the risk of cardiovascular death or hospitalization for heart failure.

• The study included patients with symptomatic chronic heart failure (NYHA class II-IV) and systolic dysfunction (left ventricular ejection fraction ≤ 40%).
• The results showed a reduction in both cardiovascular death and heart failure hospitalization.
• The treatment effect was consistent across various subgroups, including different demographic characteristics, baseline disease characteristics, and baseline concomitant medications 2.

From the Research

Acute on Chronic Congestive Heart Failure (CHF)

• Acute on chronic CHF refers to a sudden worsening of symptoms in patients with pre-existing congestive heart failure.
• The management of acute on chronic CHF involves a combination of pharmacological and non-pharmacological interventions.

Pharmacological Management

• ACE inhibitors, such as lisinopril, have been shown to be effective in reducing morbidity and mortality in patients with CHF 3.
• Beta-blockers, such as bisoprolol and carvedilol, have also been demonstrated to reduce sudden cardiac death and improve patient outcomes in CHF 4.
• Loop diuretics, such as furosemide and azosemide, are used to manage fluid overload and improve symptoms in CHF patients 5.

Comparison of Therapies

• The ATLAS study demonstrated that high doses of lisinopril were more effective than low doses in reducing the risk of major clinical events in patients with CHF 3.
• A retrospective study found that azosemide may have a potential advantage for renal protection over furosemide in patients with CHF 5.
• A systematic review highlighted the benefits of combining beta-blockers and ACE inhibitors for optimal heart failure management 4.

Non-Pharmacological Management

• No relevant information is available in the provided studies regarding non-pharmacological management of acute on chronic CHF.

Note: Study 6 is not relevant to the topic of acute on chronic CHF, as it discusses RNA recombination in foot-and-mouth disease virus.