What is the recommended treatment for a patient with congestive heart failure (CHF)?

Recommended Treatment for Congestive Heart Failure (CHF)

All patients with CHF and reduced ejection fraction should receive quadruple therapy consisting of ACE inhibitors (or ARNIs), beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors, initiated as early as possible and titrated to target doses proven in clinical trials. 1

First-Line Pharmacological Therapy

ACE Inhibitors

• Start ACE inhibitors immediately as first-line therapy in all patients with reduced left ventricular systolic function, regardless of NYHA class (I-IV). 2, 3
• Begin with low doses and titrate upward every 2 weeks to target doses: 2
  • Enalapril: Start 2.5 mg twice daily → Target 10-20 mg twice daily
  • Lisinopril: Start 2.5-5 mg once daily → Target 30-35 mg once daily
  • Ramipril: Start 2.5 mg once daily → Target 5 mg twice daily or 10 mg once daily
  • Captopril: Start 6.25 mg three times daily → Target 50-100 mg three times daily
• Before initiating ACE inhibitors, reduce or withhold diuretics for 24 hours to prevent excessive hypotension. 2, 1
• Monitor blood pressure, renal function (creatinine, BUN), and potassium 1-2 weeks after each dose increment, at 3 months, then every 6 months. 2, 1
• Accept creatinine increases up to 50% above baseline or to 3 mg/dl (266 μmol/L), whichever is greater. 2
• Accept potassium levels up to 5.5 mmol/L; seek specialist advice if potassium rises to 6.0 mmol/L. 2
• Avoid NSAIDs and potassium-sparing diuretics during initiation. 2, 1

Beta-Blockers

• Initiate beta-blockers in all stable patients (NYHA class II-IV) already on ACE inhibitors and diuretics. 2, 3
• Use only evidence-based beta-blockers with proven mortality benefit: 2
  • Bisoprolol: Start 1.25 mg once daily → Target 10 mg once daily
  • Carvedilol: Start 3.125 mg twice daily → Target 25-50 mg twice daily
  • Metoprolol CR/XL: Start 12.5-25 mg once daily → Target 200 mg once daily
• Start with very low doses and double every 2 weeks if tolerated. 2
• Do not initiate beta-blockers during acute decompensation or in patients with severe congestion (raised JVP, ascites, marked peripheral edema). 2
• Beta-blockers reduce mortality by at least 20% and decrease hospitalizations. 1
• Monitor heart rate, blood pressure, and signs of congestion; check blood chemistry 1-2 weeks after initiation and final titration. 2
• If heart rate drops below 50 bpm with worsening symptoms, halve the beta-blocker dose. 2
• Never stop beta-blockers abruptly unless absolutely necessary due to risk of rebound effects. 2

Mineralocorticoid Receptor Antagonists (MRAs)

• Add spironolactone or eplerenone for patients with persistent symptoms (NYHA class III-IV) despite ACE inhibitor and beta-blocker therapy. 2, 3, 1
• Start with low doses and monitor serum potassium and creatinine after 5-7 days, then recheck every 5-7 days until stable. 2
• Do not combine MRAs with both ACE inhibitors and ARBs due to excessive risk of hyperkalemia and renal dysfunction. 1

SGLT2 Inhibitors

• Initiate SGLT2 inhibitors early in all HFrEF patients regardless of diabetes status to reduce cardiovascular death and heart failure hospitalization. 1

Diuretics

• Always administer loop diuretics or thiazides in addition to ACE inhibitors for symptomatic relief when fluid overload is present. 2, 3
• If glomerular filtration rate (GFR) < 30 ml/min, do not use thiazides except synergistically with loop diuretics. 2
• For insufficient response: increase diuretic dose, combine loop diuretics with thiazides, or administer loop diuretics twice daily. 2
• In severe chronic heart failure with persistent fluid retention, add metolazone with frequent monitoring of creatinine and electrolytes. 2

Sequencing and Titration Strategy

The optimal approach is to initiate ACE inhibitors first, followed by beta-blockers, then add MRAs and SGLT2 inhibitors. 2, 1 However, contemporary guidelines support simultaneous initiation of all four foundational classes when feasible. 1

• Aim for target doses used in clinical trials, but remember that some medication is better than none. 2
• If target doses are not tolerated, use the highest tolerated dose. 2

Common Pitfalls and Monitoring

ACE Inhibitor-Related Issues

• Asymptomatic hypotension does not require treatment changes. 2
• For symptomatic hypotension with dizziness or confusion: reconsider nitrates and calcium channel blockers, reduce diuretics if no congestion present. 2
• ACE inhibitor-induced cough rarely requires discontinuation; only switch to ARB if cough is severe enough to prevent sleep and proven due to ACE inhibitor. 2
• It is very rarely necessary to stop an ACE inhibitor; clinical deterioration is likely if withdrawn—seek specialist advice before discontinuation. 2

Beta-Blocker-Related Issues

• Temporary symptomatic deterioration occurs in 20-30% of patients during initiation but can usually be managed by adjusting other medications. 2
• For worsening congestion during titration: double diuretic dose and/or halve beta-blocker dose. 2
• Advise patients to weigh themselves daily and increase diuretics if weight increases by 1.5-2.0 kg over 2 days. 2

Medications to Avoid

• Avoid diltiazem or verapamil in HFrEF as they increase risk of heart failure worsening. 1
• Discontinue calcium channel blockers unless absolutely essential for angina or hypertension. 2

Device Therapy Considerations

• Implantable cardioverter-defibrillators (ICDs) are indicated for primary prevention in symptomatic HF (NYHA class II-III) with LVEF ≤35% despite ≥3 months of optimal medical therapy. 1
• Cardiac resynchronization therapy (CRT) is recommended for symptomatic patients in sinus rhythm with QRS ≥150 msec, LBBB morphology, and LVEF ≤35%. 1

Patient Education and Non-Pharmacological Management

• Provide education about heart failure symptoms, what to do if symptoms worsen, and the importance of medication adherence. 3, 1
• Teach daily self-weighing to monitor fluid status. 3, 1
• Recommend daily physical activity in stable patients to prevent muscle deconditioning and improve exercise tolerance. 3, 1
• Control sodium intake, especially in severe heart failure, and avoid excessive fluid intake. 3, 1

Real-World Implementation Challenges

Recent registry data show that in patients with severe HFrEF, only 82% receive beta-blockers and 55% receive ACE inhibitors/ARBs/ARNIs, with target doses achieved in only 41% and 22% respectively. 4 Up to half of patients do not reach target doses for unknown reasons, suggesting clinical inertia by either healthcare professionals or patients. 4 Despite these challenges, treatment with beta-blockers and ACE inhibitors/ARBs/ARNIs is associated with significantly lower mortality and morbidity (adjusted HR 0.63 and 0.74 respectively). 4