What are the pillars of heart failure management?

Heart Failure Management: The Four Pillars

All patients with heart failure with reduced ejection fraction (HFrEF, EF ≤40%) should receive four foundational drug classes—ARNI/ACE inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors—as these therapies collectively reduce mortality and hospitalizations. 1

The Four Pillars of HFrEF Pharmacotherapy

Pillar 1: Renin-Angiotensin System Inhibition

First-line options:

• Sacubitril-valsartan (ARNI) is superior to enalapril, reducing cardiovascular death and HF hospitalization (HR 0.80,95% CI 0.73-0.87) and improving overall survival (HR 0.84,95% CI 0.76-0.93) in NYHA class II-IV patients with EF ≤40%. 2
• ACE inhibitors are recommended for all patients with current or prior HFrEF symptoms unless contraindicated, to reduce morbidity and mortality. 3
• ARBs serve as alternatives for ACE inhibitor-intolerant patients or as first-line therapy in patients already taking ARBs for other indications. 3

Initiation strategy:

• Start with small doses and progressively increase to target maintenance doses proven effective in clinical trials. 4
• Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increase, at 3 months, then every 6 months. 4
• Avoid potassium-sparing diuretics during ACE inhibitor initiation. 4

Pillar 2: Beta-Blockers

Only three beta-blockers have proven mortality benefit:

• Bisoprolol, carvedilol, and sustained-release metoprolol succinate are recommended for all patients with current or prior HFrEF symptoms unless contraindicated. 3
• These agents improve survival and reduce hospitalizations. 5

Critical consideration:

• Switch patients already on other beta-blockers for comorbid conditions to one of these three evidence-based agents. 3

Pillar 3: Mineralocorticoid Receptor Antagonists (MRAs)

Indications:

• Recommended for NYHA class II-IV HF with EF ≤35% to reduce morbidity and mortality. 3
• NYHA class II patients require either prior cardiovascular hospitalization or elevated natriuretic peptide levels. 3
• Also indicated post-MI in patients with EF ≤40% who develop HF symptoms or have diabetes. 3

Safety parameters before initiation:

• Creatinine ≤2.5 mg/dL (men) or ≤2.0 mg/dL (women), or eGFR >30 mL/min/1.73 m². 3
• Potassium <5.0 mEq/L. 3
• Perform close monitoring of potassium, renal function, and diuretic dosing at initiation and frequently thereafter. 3

Pillar 4: SGLT2 Inhibitors

Evidence base:

• Sodium-glucose co-transporter-2 inhibitors are now recommended as the fourth pillar in all HFrEF patients. 1
• These agents provide mortality benefit and reduce HF hospitalizations independent of diabetes status. 1

Essential Adjunctive Therapies

Diuretics for Symptom Management

Loop diuretics are first-line:

• Recommended for all patients with fluid retention to improve symptoms. 3
• Furosemide 20-40 mg once or twice daily initially, up to 600 mg maximum daily. 3
• Torsemide 10-20 mg once daily (longer duration of action, 12-16 hours) up to 200 mg maximum. 3
• Bumetanide 0.5-1.0 mg once or twice daily up to 10 mg maximum. 3

Escalation strategy for inadequate response:

• Double the loop diuretic dose up to furosemide 500 mg equivalent if no initial response. 6
• Add thiazide diuretics (sequential nephron blockade) for persistent fluid retention. 4
• Metolazone 2.5-10 mg once daily plus loop diuretic for severe chronic HF, with frequent creatinine and electrolyte monitoring. 3, 4

Critical pitfall:

• Inadequate diuresis in volume-overloaded patients is a common error that worsens outcomes. 5

Device Therapy Considerations

Cardiac resynchronization therapy (CRT):

• Consider for symptomatic patients despite optimal medical therapy with EF <35% and QRS ≥150 ms, or QRS 120-149 ms with mechanical dyssynchrony on echocardiography. 3

Implantable cardioverter-defibrillators (ICDs):

• Indicated for sustained or inducible ventricular tachyarrhythmias with EF <35%, or EF <30% with QRS ≥120 ms. 3

Non-Pharmacological Management

Patient Education and Self-Monitoring

Essential components:

• Teach daily symptom and weight monitoring, with instructions to report weight gain >2 kg in 3 days. 5
• Explain medication adherence importance and lifestyle modifications including regular physical activity and moderate sodium restriction. 5
• Provide specific education about HF symptoms recognition and self-monitoring. 5

Common pitfall:

• Neglecting patient education and self-care strategies significantly worsens outcomes. 5

Exercise Rehabilitation

Recommendation:

• Offer supervised group exercise-based rehabilitation programs with psychological and educational components to all stable HF patients without contraindications. 3
• Exercise rehabilitation reduces hospital admissions and increases long-term quality of life. 3

Medications to Avoid

Contraindicated or use with extreme caution:

• NSAIDs and COX-2 inhibitors worsen fluid retention and reduce diuretic effectiveness. 6, 4
• Class I antiarrhythmic agents. 6
• Calcium antagonists (diltiazem, verapamil) in HFrEF increase risk of worsening HF. 4
• Tricyclic antidepressants. 6
• Corticosteroids. 6
• Triple combination of ACE inhibitor + ARB + MRA increases renal dysfunction and hyperkalemia risk. 4

Transitional Care and Follow-Up

Discharge criteria:

• Acute episode resolved, congestion absent, stable oral diuretic regimen established for ≥48 hours, and long-term disease-modifying therapy optimized. 6

Post-discharge management:

• Schedule early follow-up within 7 days of hospital discharge. 5
• Refer high-risk patients to multidisciplinary HF disease management programs. 5
• Provide patient-centered discharge instructions with clear transitional care plan. 5

Critical pitfall:

• Inadequate transitional care planning leads to early readmissions. 5

Uptitration Strategy

Systematic approach:

• Failure to uptitrate medications to target doses proven in clinical trials is a common error. 5
• Progressively increase each pillar medication to evidence-based target doses unless limited by hypotension, renal dysfunction, or hyperkalemia. 4
• Monitor closely during uptitration with blood pressure, renal function, and electrolyte checks. 4