What are the symptoms and treatment options for a patient with heart failure?

Heart Failure: Symptoms and Treatment

Start all four foundational medication classes (SGLT2 inhibitor, mineralocorticoid receptor antagonist, beta-blocker, and ARNI or ACE inhibitor) simultaneously as soon as heart failure with reduced ejection fraction is diagnosed, which provides approximately 73% mortality reduction over 2 years. 1

Clinical Presentation and Symptoms

Key symptoms to identify:

• Exertional breathlessness (dyspnea) is the cardinal symptom, particularly with physical activity 2
• Pulmonary edema manifesting as orthopnea, paroxysmal nocturnal dyspnea, or acute respiratory distress 2
• Peripheral edema in the ankles, legs, or sacral area 2
• Fatigue and exercise intolerance due to inadequate cardiac output 2
• Rapid weight gain (>2 kg in 3 days) indicating fluid retention 2

Physical examination findings:

• Elevated jugular venous pressure 3
• Pulmonary rales or crackles 3
• Third heart sound (S3 gallop) 3
• Hepatomegaly and ascites in severe cases 4

Diagnostic confirmation requires echocardiography showing reduced left ventricular ejection fraction (LVEF ≤40-45%) or preserved ejection fraction with diastolic dysfunction. 2

Pharmacological Treatment Algorithm

First-Line Therapy (Start Immediately Upon Diagnosis)

For Heart Failure with Reduced Ejection Fraction (HFrEF):

1. SGLT2 Inhibitor - reduces cardiovascular death and hospitalization regardless of diabetes status, with minimal blood pressure effect 1

2. Mineralocorticoid Receptor Antagonist (MRA) - provides at least 20% mortality reduction and reduces sudden cardiac death 1

3. Beta-Blocker - reduces mortality by at least 20% and decreases sudden cardiac death 1, 5

   • Start with low doses: carvedilol 3.125 mg twice daily or metoprolol succinate 12.5-25 mg once daily 1, 5
   • Titrate every 1-2 weeks to target doses shown effective in trials 2, 5
   • For heart failure patients: start metoprolol succinate 25 mg once daily for NYHA Class II, or 12.5 mg once daily for more severe heart failure 5
   • Double the dose every two weeks up to 200 mg or maximum tolerated dose 5

4. ARNI (Sacubitril/Valsartan) - preferred over ACE inhibitors, providing superior mortality reduction of at least 20% 1

   • Starting dose: 24 mg/26 mg twice daily 1
   • If ARNI contraindicated or not tolerated, use ACE Inhibitor as first-line therapy 2
   • Uptitrate to target doses shown effective in large trials, not based on symptomatic improvement alone 2

Symptomatic Relief

Diuretics (Loop Diuretics - Furosemide):

• Essential when fluid overload is present with pulmonary congestion or peripheral edema 2, 6
• Results in rapid improvement of dyspnea and increased exercise tolerance 2
• Must always be combined with ACE inhibitors or ARNI 2
• Caution: Use carefully in isolated right ventricular failure to avoid compromising RV filling pressure 6

Flexible diuretic dosing:

• Patients should increase their diuretic dose if sudden weight gain >2 kg in 3 days occurs and alert the healthcare team 2
• Establish stable oral diuretic regimen for at least 48 hours before discharge 6

Medications to Avoid

The following drugs should be avoided or used with extreme caution: 2, 6

• NSAIDs and COX-2 inhibitors
• Class I antiarrhythmic agents
• Calcium antagonists (verapamil, diltiazem, short-acting dihydropyridines)
• Tricyclic antidepressants
• Corticosteroids
• Lithium
• Combination of ACE inhibitors, ARBs, and mineralocorticoid receptor antagonists

Device Therapy

Implantable Cardioverter-Defibrillator (ICD):

• Indicated for primary prevention in symptomatic HF patients (NYHA Class II-III) with LVEF ≤35% despite ≥3 months of optimal medical therapy 1
• For secondary prevention in patients who recovered from ventricular arrhythmia causing hemodynamic instability 1

Cardiac Resynchronization Therapy (CRT):

• Indicated for symptomatic HFrEF patients in sinus rhythm with QRS duration ≥150 msec and left bundle branch block morphology with LVEF ≤35% despite optimal medical therapy 1

Non-Pharmacological Management

Patient Education (Essential Components)

Teach patients to: 2, 7

• Understand the pathophysiology of heart failure and why symptoms occur
• Monitor and recognize worsening signs: increased dyspnea, fatigue, peripheral edema
• Weigh themselves daily and contact healthcare provider if weight increases by 2-3 kg over several days 2, 7
• Understand medication indications, dosing, effects, and common side effects
• Maintain medication adherence

Dietary Modifications

Sodium restriction:

• Particularly important in patients with severe heart failure 2, 7

Fluid management:

• Fluid restriction of 1.5-2 L/day should be considered only in patients with severe symptoms, especially with hyponatremia 2
• Routine fluid restriction in mild to moderate symptoms does not confer clinical benefit 2

Alcohol:

• Limit to 10-20 g/day (1-2 glasses of wine/day) 2
• Complete abstinence required in suspected alcohol-induced cardiomyopathy 2

Exercise and Physical Activity

Exercise training programs are recommended for stable NYHA class II-III patients and should not be withheld due to concerns about cardiac deconditioning 2, 7

• Rest is not encouraged in stable conditions as it promotes muscle deconditioning 2, 7
• Daily physical and leisure activities should be maintained in stable patients 2, 7
• In acute heart failure or destabilization, physical rest or bed rest is recommended 2

Weight Management

Weight reduction in obese patients (BMI >30 kg/m²) should be considered to prevent progression of HF, decrease symptoms, and improve well-being 2

• Caution: In moderate to severe HF, weight reduction should not routinely be recommended since unintentional weight loss and anorexia are common problems 2

Monitoring and Follow-Up

Regular monitoring is crucial: 1

• Blood pressure, renal function, and electrolytes during initial phase (first 3 months)
• Reassess every 6 months during maintenance phase
• Monitor renal function, electrolytes, potassium, and sodium daily during IV therapy and when adjusting renin-angiotensin-aldosterone system antagonists 6
• Maintain oxygen saturation above 90% at all times in acute presentations 6

Reassess symptoms, functional status, and LVEF regularly with timely referral to a heart failure specialist if persistent advanced symptoms or worsening occurs 1

Special Considerations for Right Heart Failure

If right heart failure is suspected:

• Immediately identify the underlying etiology as management differs dramatically based on cause 6
• Progressive isolated RV failure suggests pulmonary hypertension; acute presentations may indicate RV infarction or pulmonary embolism 6

For RV infarction:

• Perform urgent coronary angiography and revascularization immediately 6
• Administer volume loading with normal saline (500-ml bolus, followed by 500 ml/h) unless signs of left heart volume overload are present 6

For pulmonary hypertension-related RHF:

• Pulmonary vasodilators are the cornerstone of treatment including type V phosphodiesterase inhibitors, endothelin antagonists, and prostacyclin analogues 6

Common Pitfalls to Avoid

• Do not delay initiation of all four foundational medications - start simultaneously, not sequentially 1
• Do not titrate ACE inhibitors or ARNI based on symptomatic improvement alone - uptitrate to target doses from clinical trials 2
• Do not prescribe prolonged bed rest in stable patients - this worsens deconditioning 7
• Do not apply overly restrictive fluid limitations in patients without severe congestion 7
• Do not use diuretics alone - always combine with ACE inhibitors or ARNI 2
• Explain to patients that beneficial effects may be delayed and side effects may occur; it might take months to uptitrate and assess full drug effects 2