What is the recommended treatment for a patient with Congestive Heart Failure (CHF)?

Treatment of Congestive Heart Failure (CHF)

All patients with CHF and reduced ejection fraction should receive simultaneous initiation of four foundational medication classes: ACE inhibitors (or ARNI), beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors, along with diuretics for symptom control. 1, 2

First-Line Therapy: The Four Pillars

ACE Inhibitors

• Start ACE inhibitors immediately in all patients with symptomatic CHF (NYHA class I-IV) as first-line therapy alongside beta-blockers 3
• Begin with low doses and titrate upward every 2 weeks to target doses proven in clinical trials 3, 2:
  • Enalapril: Start 2.5 mg twice daily → Target 10-20 mg twice daily 3
  • Lisinopril: Start 2.5-5.0 mg once daily → Target 30-35 mg once daily 3
  • Ramipril: Start 2.5 mg once daily → Target 5 mg twice daily or 10 mg once daily 3
• ACE inhibitors reduce mortality, hospital admissions, and improve NYHA class and quality of life 3
• Monitor blood chemistry (urea, creatinine, potassium) and blood pressure before initiation, 1-2 weeks after each dose increase, and at 3-6 month intervals 3

Beta-Blockers

• Initiate beta-blockers simultaneously with ACE inhibitors in stable patients (NYHA class II-IV) 3, 1, 2
• Use only evidence-based agents that reduce mortality 3, 1:
  • Bisoprolol: Start 1.25 mg once daily → Target 10 mg once daily 3
  • Carvedilol: Start 3.125 mg twice daily → Target 25-50 mg twice daily 3
  • Metoprolol CR/XL: Start 12.5-25 mg once daily → Target 200 mg once daily 3
• Beta-blockers reduce mortality by at least 20% and should be started early in the disease course 3, 1
• Double doses at 2-week intervals minimum, monitoring heart rate, blood pressure, and clinical status 3
• Temporary symptomatic deterioration occurs in 20-30% of patients during titration—increase diuretics first before reducing beta-blocker dose 3, 1

Mineralocorticoid Receptor Antagonists (MRAs)

• Add spironolactone in patients with NYHA class III-IV heart failure despite ACE inhibitor and diuretic therapy 3, 1
• Start with 25 mg daily only if serum potassium <5.0 mmol/L and creatinine <2.5 mg/dL (221 μmol/L) 3
• Check potassium and creatinine after 4-6 days of initiation 1
• Spironolactone reduces mortality by 57 deaths per 1000 patient-years and hospitalizations by 138 per 1000 patient-years 3

SGLT2 Inhibitors

• Initiate SGLT2 inhibitors early regardless of diabetes status as the fourth pillar of therapy 1
• These agents reduce cardiovascular death and heart failure hospitalization 1

Diuretics for Symptom Management

• Use loop diuretics in all patients with signs or symptoms of fluid overload to improve symptoms and exercise capacity 3, 2
• Thiazides can be used if eGFR >30 mL/min, but switch to loop diuretics below this threshold 2
• Patients should weigh themselves daily and increase diuretic dose if weight increases persistently (2 days) by 1.5-2.0 kg 3

Critical Monitoring and Problem-Solving

Hypotension During Titration

• Asymptomatic low blood pressure does not require treatment changes 3
• For symptomatic hypotension: reduce nitrates and calcium channel blockers first, then consider reducing diuretics if no congestion present—avoid reducing ACE inhibitors or beta-blockers 3

Renal Function Monitoring

• An increase in creatinine up to 50% above baseline or to 3 mg/dL (266 μmol/L), whichever is greater, is acceptable 3
• If creatinine or potassium rise excessively, stop NSAIDs and non-essential vasodilators, reduce diuretics if no congestion, then halve ACE inhibitor dose 3
• Seek specialist advice if potassium rises to 6.0 mmol/L or creatinine increases by 100% or above 4 mg/dL (354 μmol/L) 3

Cough with ACE Inhibitors

• ACE inhibitor-induced cough rarely requires discontinuation 3
• Exclude pulmonary edema first 3
• Only substitute an angiotensin receptor blocker if cough is proven due to ACE inhibitor and severely impacts sleep 3

Beta-Blocker Titration Issues

• For worsening congestion: double diuretic dose first, halve beta-blocker only if diuretics don't work 3
• For heart rate <50 bpm with worsening symptoms: halve beta-blocker dose, review other heart rate-slowing drugs, arrange ECG to exclude heart block 3
• Never stop beta-blockers suddenly unless absolutely necessary 3

Advanced Therapy Considerations

ARNI (Sacubitril/Valsartan)

• Replace ACE inhibitor with sacubitril/valsartan in ambulatory patients who remain symptomatic despite optimal triple therapy 2
• This further reduces cardiovascular death and hospitalization 2

Digoxin

• Reserve for patients in sinus rhythm with persistent symptoms despite ACE inhibitor and diuretic treatment 1
• Usual dose: 0.25-0.375 mg daily 1
• Avoid in bradycardia, second- or third-degree AV block, sick sinus syndrome, and electrolyte abnormalities 1

Medications to Avoid

The following drugs should be avoided or used with extreme caution 3, 2:

• NSAIDs and COX-2 inhibitors 3
• Class I antiarrhythmic agents 3
• Calcium antagonists (verapamil, diltiazem, short-acting dihydropyridines) 3, 2
• Tricyclic antidepressants 3
• Corticosteroids 3

Critical Pitfall to Avoid

Never combine ACE inhibitor with ARB and MRA simultaneously—this dramatically increases risk of renal dysfunction and life-threatening hyperkalemia 1, 2

Non-Pharmacological Management

• Sodium restriction is more important in advanced than mild heart failure 3
• Fluid restriction of 1.5-2 L/day in advanced heart failure 3
• Moderate alcohol intake (one beer, 1-2 glasses wine/day) is permitted except in alcoholic cardiomyopathy 3
• Exercise training programs are encouraged in stable NYHA class II-III patients to improve skeletal muscle function and functional capacity 3
• Physical rest or bed rest is recommended only in acute heart failure or destabilization 3

When to Seek Specialist Advice

Refer patients with 3:

• Severe (NYHA class IV) CHF 3
• Significant renal dysfunction (creatinine >2.5 mg/dL or >221 μmol/L) 3
• Hyperkalaemia (>5.0 mmol/L) 3
• Symptomatic or severe asymptomatic hypotension (systolic BP <90 mmHg) 3
• Current or recent (4 weeks) exacerbation requiring hospitalization 3
• Heart block or heart rate <60/min 3
• Suspected asthma or severe bronchial disease 1