What are the management strategies for heart failure (congestive heart failure)?

From the Guidelines

Heart failure management should prioritize a comprehensive approach to reduce symptoms, improve quality of life, and extend survival, with the most recent guidelines from 2021 1 emphasizing the importance of optimized medical and device management.

Key Components of Management

• Lifestyle modifications: sodium restriction (2-3g daily), fluid restriction (1.5-2L daily), regular exercise, smoking cessation, and limiting alcohol intake
• Pharmacotherapy:
  • ACE inhibitors (like enalapril 2.5-20mg twice daily or lisinopril 10-40mg daily) or ARBs (such as losartan 25-100mg daily) to reduce afterload and remodeling
  • Beta-blockers (carvedilol 3.125-25mg twice daily, metoprolol succinate 12.5-200mg daily, or bisoprolol 1.25-10mg daily) to reduce sympathetic stimulation and improve cardiac function
  • Diuretics, particularly loop diuretics like furosemide (20-240mg daily), for symptom relief by reducing fluid overload
  • Aldosterone antagonists (spironolactone 12.5-50mg daily) for patients with persistent symptoms despite optimal therapy
  • Newer agents: SGLT2 inhibitors (dapagliflozin 10mg daily or empagliflozin 10mg daily) and angiotensin receptor-neprilysin inhibitors (sacubitril/valsartan 24/26mg to 97/103mg twice daily) which can replace ACE inhibitors in appropriate patients

Device Therapy and Advanced Care

• Device therapy: implantable cardioverter-defibrillators and cardiac resynchronization therapy should be considered for eligible patients
• Advanced heart failure may require mechanical circulatory support or heart transplantation
• Regular monitoring of symptoms, fluid status, renal function, and electrolytes is essential for optimal management, as highlighted in the 2016 ESC guidelines 1 and the 2019 ACC/AHA guidelines comparison 1

Multidisciplinary Approach

• A multidisciplinary approach, including cardiologists, primary care physicians, nurses, pharmacists, and other healthcare professionals, is crucial for optimal management, as emphasized in the 2012 ESC guidelines 1 and the 2014 ACCF and AHA guidelines 1

From the FDA Drug Label

In two placebo controlled, 12-week clinical studies compared the addition of lisinopril up to 20 mg daily to digitalis and diuretics alone. The combination of lisinopril, digitalis and diuretics reduced the following signs and symptoms of heart failure: edema, rales, paroxysmal nocturnal dyspnea and jugular venous distention In one of the studies, the combination of lisinopril, digitalis and diuretics reduced orthopnea, presence of third heart sound and the number of patients classified as NYHA Class III and IV; and improved exercise tolerance. A large (over 3,000 patients) survival study, the ATLAS Trial, comparing 2. 5 mg and 35 mg of lisinopril in patients with systolic heart failure, showed that the higher dose of lisinopril had outcomes at least as favorable as the lower dose During baseline-controlled clinical trials, in patients with systolic heart failure receiving digitalis and diuretics, single doses of lisinopril resulted in decreases in pulmonary capillary wedge pressure, systemic vascular resistance and blood pressure accompanied by an increase in cardiac output and no change in heart rate.

Lisinopril is used in the management of heart failure. The drug can be used in combination with digitalis and diuretics to reduce signs and symptoms of heart failure, such as:

• Edema
• Rales
• Paroxysmal nocturnal dyspnea
• Jugular venous distention It can also reduce orthopnea, presence of third heart sound, and improve exercise tolerance. The ATLAS Trial showed that higher doses of lisinopril had outcomes at least as favorable as lower doses in patients with systolic heart failure 2.

From the Research

Heart Failure Management Overview

• Heart failure with reduced ejection fraction (HFrEF) is a complex and progressive clinical condition characterized by dyspnea and functional impairment, with a high burden of mortality and readmission rate 3.
• The management of HFrEF involves a combination of medications, including diuretics, quadruple therapy (Angiotensin receptor blocker/neprilysin inhibitors, evidence-based beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter 2 inhibitors), and device therapies such as implanted cardioverter defibrillators, cardiac resynchronization therapy, and trans catheter mitral valve repair 3, 4, 5.

Medication Management

• Guideline-directed medical therapy is vastly underutilized in real-world clinical practice, despite compelling evidence of clinical benefit 3.
• The use of quadruple therapy has been shown to reduce hospitalizations, all-cause mortality, and cardiovascular mortality in patients with HFrEF 3, 6.
• Other medications, such as intravenous iron, ivabradine, hydralazine/nitrates, and vericiguat, may also have a role in certain subgroups of HFrEF patients 3, 7.

Device Therapies

• Cardiac rhythm management (CRM) devices, such as implanted cardioverter defibrillators and cardiac resynchronization therapy, are recommended for patients with HFrEF, with a high level of evidence 5.
• Device therapy can reduce mortality and morbidity in patients with HFrEF, and practical guidance on patient referral, device selection, implant timing, and patient-centred follow-up is available 5.

Treatment Approaches

• A novel approach to medical management of HFrEF involves the rapid initiation of all four foundational therapies (renin-angiotensin-neprilysin inhibitors, β-blockers, mineralocorticoid antagonists, and sodium-glucose cotransporter inhibitors) followed by their titration to target doses 6.
• The use of a mnemonic, such as BANDAID(2), can assist physicians in remembering the key components of evidence-based treatment for systolic heart failure, including beta-blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, nitrate-hydralazine, diuretics, aldosterone antagonist, ivabradine, devices, and digoxin 7.