What are the initial treatment recommendations for a patient with congestive heart failure (CHF)?

Initial Treatment of Congestive Heart Failure

Start all patients with symptomatic CHF on an ACE inhibitor plus a beta-blocker as foundational therapy, adding loop diuretics for fluid overload, and escalate to mineralocorticoid receptor antagonists if symptoms persist despite optimal dual therapy. 1, 2

Foundational Pharmacotherapy

ACE Inhibitors (First-Line)

• Initiate ACE inhibitors immediately in all patients with reduced left ventricular systolic function, regardless of symptom severity 1, 2, 3
• Start with low doses and titrate gradually to target maintenance doses proven effective in clinical trials 1, 3
• Before starting: Review and potentially reduce diuretic doses for 24 hours to avoid excessive hypotension 1
• Monitor blood pressure, renal function (creatinine), and electrolytes (potassium) at 1-2 weeks after each dose increase, then at 3 months, then every 6 months 1, 3
• Critical pitfall: Avoid NSAIDs and initially withhold potassium-sparing diuretics during ACE inhibitor initiation to prevent hyperkalemia 1

Beta-Blockers (Co-First-Line)

• Add beta-blockers to ACE inhibitors for all stable patients with reduced ejection fraction (NYHA Class II-IV) 1, 2, 3
• Only initiate in stable patients already on ACE inhibitors and diuretics—never during acute decompensation 1
• Beta-blockers reduce both heart failure hospitalizations and mortality 1, 3

Symptomatic Relief

Diuretics

• Administer loop diuretics (or thiazides if GFR >30 mL/min) for any signs of fluid overload—pulmonary congestion or peripheral edema 1, 2
• Always combine with ACE inhibitors; never use diuretics as monotherapy long-term due to neurohormonal activation 1, 4
• For acute heart failure: Start with 20-40 mg IV furosemide (or equivalent) in diuretic-naive patients; use doses at least equivalent to prior oral doses in patients already on diuretics 1
• Give as intermittent boluses or continuous infusion, adjusting based on urine output and symptoms 1
• Monitor symptoms, urine output, renal function, and electrolytes regularly during IV diuretic use 1
• For insufficient response: Increase diuretic dose, combine loop diuretics with thiazides, or administer loop diuretics twice daily 1

Escalation Therapy

Mineralocorticoid Receptor Antagonists (MRAs)

• Add spironolactone or other MRA for patients who remain symptomatic (NYHA Class III-IV) despite ACE inhibitor and beta-blocker therapy 1, 2, 3
• MRAs reduce both heart failure hospitalization and death 1, 2
• Monitor potassium and creatinine closely: check at 5-7 days after initiation, recheck every 5-7 days until stable 1, 3

Sacubitril/Valsartan (ARNI)

• Replace ACE inhibitor with sacubitril/valsartan in ambulatory patients with HFrEF who remain symptomatic despite optimal triple therapy (ACE inhibitor, beta-blocker, MRA) 1, 2
• In the PARADIGM-HF trial, sacubitril/valsartan (200 mg twice daily) reduced the composite endpoint of cardiovascular death or heart failure hospitalization by 20% compared to enalapril (HR 0.80, p<0.0001) 5
• Also improved all-cause mortality (HR 0.84, p=0.0009) 5

Alternative Agents

Angiotensin Receptor Blockers (ARBs)

• Use ARBs only if ACE inhibitors are not tolerated due to intractable cough or angioedema 1, 4
• Critical warning: Never combine ACE inhibitor + ARB + MRA due to severe risk of renal dysfunction and hyperkalemia 1

Hydralazine/Isosorbide Dinitrate

• Use this combination if both ACE inhibitors and ARBs are not tolerated 4
• Particularly recommended in African American patients as add-on therapy 6

Digoxin

• Add digoxin for patients with persistent symptoms despite ACE inhibitor and diuretic therapy, or for rate control in atrial fibrillation 1
• Target low serum concentrations (≤1.0 ng/dL) 4

Medications to Avoid

• Never use diltiazem or verapamil in HFrEF—they worsen heart failure and increase hospitalizations 1
• Avoid thiazolidinediones (glitazones)—they increase heart failure risk 1
• Avoid NSAIDs and COX-2 inhibitors—they worsen heart failure and increase hospitalizations 1

Initial Assessment Requirements

Before initiating therapy, obtain: 1

• Complete blood count, comprehensive metabolic panel (electrolytes, calcium, magnesium, BUN, creatinine), fasting glucose, lipid profile, liver function tests, thyroid-stimulating hormone, urinalysis 1
• 12-lead ECG and chest X-ray (PA and lateral) 1
• Two-dimensional echocardiography with Doppler to assess LVEF, LV size, wall thickness, and valve function 1
• Coronary angiography if angina present or significant ischemia suspected (unless patient not eligible for revascularization) 1

Non-Pharmacological Measures

• Enroll patients in multidisciplinary heart failure management programs to reduce hospitalization and mortality 1
• Encourage regular aerobic exercise in stable patients to improve functional capacity, symptoms, and reduce heart failure hospitalization risk 1
• Control sodium intake in severe heart failure; avoid excessive fluid intake 1, 3
• Provide education on symptom recognition, daily self-weighing, and when to seek medical attention 1, 3