What are the guidelines for treating a patient with heart failure, including recommended medications and lifestyle modifications?

Guidelines for Treatment of Heart Failure

All patients with heart failure and reduced ejection fraction (HFrEF) must receive quadruple foundational therapy: ACE inhibitors (or sacubitril/valsartan), beta-blockers, diuretics when fluid overloaded, and aldosterone antagonists for NYHA Class III-IV disease to reduce mortality and hospitalizations. 1, 2

Pharmacological Treatment Algorithm

First-Line Therapy: ACE Inhibitors

• Start ACE inhibitors immediately as first-line therapy in all patients with reduced left ventricular systolic function (ejection fraction ≤40%). 1, 2
• Begin with low doses and titrate upward every 1-2 weeks to target maintenance doses proven effective in large clinical trials. 1
• Avoid excessive diuresis for 24 hours before ACE inhibitor initiation to minimize hypotension risk; consider starting in the evening when supine. 1
• Monitor blood pressure, renal function, and electrolytes at 1-2 weeks after each dose increment, at 3 months, then every 6 months. 1
• If renal function deteriorates substantially (creatinine increases >50% or to 3 mg/dL), stop ACE inhibitor treatment. 1, 3
• Avoid NSAIDs and potassium-sparing diuretics during ACE inhibitor initiation. 1

Second-Line Therapy: Beta-Blockers

• Add beta-blockers for all stable patients with HFrEF (NYHA Class II-IV) already on ACE inhibitors and diuretics. 1, 2, 3
• Beta-blockers reduce mortality, prevent heart failure progression, and improve functional class. 1, 4
• Continue beta-blockers during hospitalization unless the patient is hemodynamically unstable (systolic BP <90 mmHg). 3
• For heart failure patients, start metoprolol succinate at 12.5-25 mg once daily and double the dose every 2 weeks to a target of 200 mg daily as tolerated. 5

Essential Symptomatic Therapy: Diuretics

• Diuretics are mandatory when fluid overload manifests as pulmonary congestion or peripheral edema. 1, 2
• Loop diuretics or thiazides should always be administered in combination with ACE inhibitors. 1
• If GFR <30 ml/min, do not use thiazides except synergistically with loop diuretics. 1
• For insufficient diuretic response: increase the dose, combine loop diuretics with thiazides, administer loop diuretics twice daily, or add metolazone in severe cases with frequent creatinine and electrolyte monitoring. 1, 3

Advanced Heart Failure: Aldosterone Antagonists

• Add spironolactone for NYHA Class III-IV patients already on ACE inhibitors and diuretics to improve survival and reduce morbidity. 1, 2, 3
• Start with low-dose spironolactone, check serum potassium and creatinine after 5-7 days, and titrate accordingly. 1
• If potassium rises to 5.0-5.5 mmol/L, reduce aldosterone antagonist dose by 50%; stop if potassium >5.5 mmol/L. 3

Advanced Therapy: Sacubitril/Valsartan (ARNI)

• Consider replacing ACE inhibitors with sacubitril/valsartan in patients who remain symptomatic despite optimal therapy with ACE inhibitors, beta-blockers, and diuretics. 3, 6
• Allow a 36-hour washout period when switching from ACE inhibitors to sacubitril/valsartan. 6
• Start at 49/51 mg twice daily and double the dose after 2-4 weeks to the target maintenance dose of 97/103 mg twice daily. 6
• Sacubitril/valsartan reduces cardiovascular death and heart failure hospitalization more effectively than ACE inhibitors alone. 7, 8

Non-Pharmacological Management

Patient Education (Mandatory Components)

• Explain heart failure pathophysiology, symptom recognition (dyspnea, fatigue, edema), and when to seek immediate help. 1, 2
• Teach daily self-weighing after waking, before dressing, after voiding, and before eating. 1, 2
• Instruct patients to increase diuretic dose and contact healthcare team if weight increases >2 kg over 3 days. 2, 3
• Emphasize strict medication adherence to both pharmacological and lifestyle prescriptions. 1, 2

Lifestyle Modifications

• Smoking cessation is mandatory; nicotine replacement therapies are acceptable. 1, 2
• Restrict sodium intake to <6 g/day, particularly in severe heart failure. 1, 4
• Limit fluid intake to 1.5-2 L/day in severe heart failure. 1, 4
• Avoid excessive alcohol consumption. 1

Exercise and Activity

• Regular daily physical activity is recommended for stable NYHA Class II-III patients to prevent muscle deconditioning. 1, 2
• Rest is not encouraged in stable conditions. 1
• Exercise training programs improve quality of life and functional capacity. 1, 2

Management of Acute Decompensated Heart Failure

Immediate Treatment

• Administer IV loop diuretics as the cornerstone of acute decompensation treatment. 3
• Ensure IV diuretic doses are at least equivalent to oral doses in patients on chronic therapy. 4, 3
• If inadequate response after 24-48 hours, add thiazide diuretic (metolazone) or acetazolamide as adjunctive therapy. 3

Medication Management During Hospitalization

• Continue ACE inhibitors and beta-blockers during hospitalization unless the patient is hemodynamically unstable (systolic BP <90 mmHg). 4, 3
• Discontinuing ACE inhibitors during heart failure hospitalization increases 30-day mortality (adjusted HR 1.92) and 1-year mortality (adjusted HR 1.35). 9
• Reserve IV dobutamine only for cardiogenic shock with both pulmonary congestion and peripheral hypoperfusion, and limit use to <48 hours. 3

Monitoring Parameters

• Monitor blood pressure frequently to detect symptomatic hypotension. 3
• An increase in creatinine up to 50% above baseline or to 3 mg/dL is acceptable during aggressive diuresis. 3
• Assess for adequate decongestion: resolution of dyspnea, decreased jugular venous pressure, reduced peripheral edema. 3

Critical Pitfalls to Avoid

Medication Errors

• Never use NSAIDs or COX-2 inhibitors—they worsen heart failure and interfere with ACE inhibitor efficacy. 1, 2
• Avoid calcium channel blockers (diltiazem, verapamil) as they have negative inotropic effects and are potentially harmful. 3
• Never start potassium-sparing diuretics during ACE inhibitor initiation due to dangerous hyperkalemia risk. 1, 2

Dosing and Titration Errors

• Failure to uptitrate medications to target doses proven in clinical trials reduces survival benefit. 2
• Inadequate diuresis in volume-overloaded patients leads to persistent symptoms and readmissions. 2

Discharge Planning Errors

• Schedule early follow-up within 7 days of hospital discharge. 2
• Before discharge, patients should have minimal or no signs of congestion. 3
• Refer high-risk patients to specialized heart failure programs to reduce readmissions and mortality. 2, 3