From the Guidelines
The treatment of congestive heart failure (CHF) should prioritize a comprehensive approach combining medications, lifestyle modifications, and sometimes devices or surgery, with a focus on reducing morbidity, mortality, and improving quality of life, as recommended by the most recent guidelines 1. The primary goal of CHF treatment is to alleviate symptoms, slow disease progression, and improve survival.
- First-line medications include ACE inhibitors (like lisinopril 10-40mg daily) or ARBs (such as losartan 25-100mg daily) to reduce afterload and remodeling, as supported by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.
- Beta-blockers (metoprolol succinate 12.5-200mg daily or carvedilol 3.125-25mg twice daily) are added to reduce workload on the heart, as recommended by the European Society of Cardiology guidelines 1.
- Diuretics like furosemide (20-80mg daily or twice daily) help manage fluid overload, with the dose titrated according to the patient's response and tolerance, as suggested by the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1.
- For moderate to severe CHF, aldosterone antagonists (spironolactone 12.5-50mg daily) may be added, as indicated by the 2022 European Journal of Heart Failure article on quality indicators for the care and outcomes of adults with heart failure 1.
- In advanced cases, medications like sacubitril/valsartan (24/26mg to 97/103mg twice daily) can further reduce mortality, as shown in the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. Lifestyle modifications are crucial, including:
- Sodium restriction (<2g daily)
- Fluid restriction if needed
- Daily weight monitoring
- Regular exercise as tolerated
- Smoking cessation These treatments work by reducing cardiac workload, preventing harmful remodeling, and managing the neurohormonal imbalances that worsen heart failure over time. Treatment must be individualized based on heart failure type (reduced vs. preserved ejection fraction), severity, and comorbidities, as emphasized by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.
From the Research
CHF Treatment Overview
- CHF (Congestive Heart Failure) treatment has evolved over the years, with a focus on reducing morbidity and mortality in patients with reduced ejection fraction (HFrEF) 2, 3, 4, 5, 6.
- The current treatment approach involves a combination of medications, including angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRA), and sodium-glucose cotransporter 2 (SGLT2) inhibitors 2, 5.
Medication Classes
- Four medication classes, referred to as Foundational Therapy, have been shown to confer rapid and robust reduction in morbidity and mortality in patients with HFrEF:
- Renin-angiotensin-neprilysin inhibitors
- β-blockers
- Mineralocorticoid antagonists
- Sodium-glucose cotransporter inhibitors 2.
- Additional medication classes, such as angiotensin receptor-neprilysin inhibitors, ivabradine, levosimendan, and omega-3 fatty acids, have also been shown to be effective in improving cardiac function and reducing morbidity and mortality in patients with HFrEF 3, 4, 5.
Treatment Approach
- The treatment approach for CHF involves rapid initiation of all four Foundational Therapies, followed by titration to target doses 2.
- Multiple simultaneous drug changes with each patient encounter, attention to patient-specific factors, and leveraging inpatient care and alternative modes of care are also important principles in CHF treatment 2.
- Disease management programs and telemonitoring can also reduce hospitalizations and mortality in patients with CHF 6.
Device-Based Therapies
- Implantable cardioverter-defibrillators and biventricular pacemakers have been shown to improve mortality and function in selected patients with CHF 3, 6.
- Other device-based therapies, such as baroreflex modulation and cardiac contractility modulation, are still being investigated and their utility needs to be further established 3.