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 heart failure and reduced ejection fraction (HFrEF) on triple therapy: an ACE inhibitor, a beta-blocker, and a diuretic (if fluid overload is present), then add a mineralocorticoid receptor antagonist if symptoms persist despite this regimen. 1, 2

Immediate Diagnostic Assessment

Before initiating treatment, perform these essential evaluations:

• Obtain transthoracic echocardiography (TTE) to measure left ventricular ejection fraction (LVEF) and classify the patient as HFrEF (LVEF ≤40%), HFmrEF (LVEF 41-49%), or HFpEF (LVEF ≥50%), as this determines the entire treatment algorithm 1, 2
• Measure plasma natriuretic peptides (BNP, NT-proBNP, or MR-proANP) to confirm the diagnosis, particularly in patients presenting with acute dyspnea 1
• Obtain baseline laboratory tests: complete blood count, serum electrolytes (including potassium, calcium, magnesium), renal function (BUN, creatinine), fasting glucose, lipid profile, liver function tests, and thyroid-stimulating hormone 1
• Perform 12-lead ECG and chest radiograph to identify underlying causes and assess for pulmonary congestion 1

First-Line Pharmacological Therapy for HFrEF

ACE Inhibitor Initiation (Start Immediately)

Begin ACE inhibitor therapy in all patients with reduced LVEF, starting with low doses and titrating upward to target maintenance doses proven effective in clinical trials. 1, 2

Specific initiation protocol: 1, 3

• Starting dose: 2.5-5 mg once daily of lisinopril (or equivalent ACE inhibitor)
• Use 2.5 mg in patients with hyponatremia (serum sodium <130 mEq/L), low systolic blood pressure (≤120 mmHg), or on high-dose diuretics 1, 3
• Target dose: Titrate to 10-40 mg once daily as tolerated 3
• Before starting: Review and potentially reduce diuretic dose for 24 hours to minimize first-dose hypotension 1
• Monitoring schedule: Check blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, then every 6 months 1, 4

Critical safety parameters: 1

• Continue ACE inhibitor if creatinine increases up to 50% above baseline or to 3 mg/dL (266 μmol/L), whichever is greater
• Stop ACE inhibitor only if renal function deteriorates substantially beyond these thresholds
• Avoid potassium-sparing diuretics during ACE inhibitor initiation
• Avoid NSAIDs, which antagonize ACE inhibitor effects and worsen renal function

Beta-Blocker Addition (Add Once Stable on ACE Inhibitor)

Add a beta-blocker for all stable patients with HFrEF (NYHA Class II-IV) who are already on ACE inhibitors and diuretics. 1, 5

• Beta-blockers reduce mortality, prevent heart failure progression, and decrease hospitalizations 1, 4
• Initiate only after the patient is stabilized on ACE inhibitor therapy (not during acute decompensation) 1
• Start with low doses and titrate slowly to target maintenance doses used in clinical trials 1

Diuretic Therapy (For Fluid Overload)

Administer loop diuretics when signs or symptoms of fluid overload are present: pulmonary congestion, elevated jugular venous pressure, or peripheral edema. 1

Dosing strategy: 1

• Initial dose: 20-40 mg IV furosemide (or equivalent) for new-onset heart failure or patients not on chronic diuretics
• For patients already on oral diuretics, the initial IV dose should equal or exceed their oral dose
• Administer as intermittent boluses or continuous infusion, adjusting based on symptoms and urine output
• Monitor closely: Symptoms, urine output, daily weights, renal function, and electrolytes 1

For inadequate diuretic response: 1, 4

• Increase loop diuretic dose
• Combine loop diuretics with thiazides (avoid thiazides if GFR <30 mL/min unless used synergistically with loop diuretics)
• In severe chronic heart failure, add metolazone with frequent monitoring of creatinine and electrolytes

Mineralocorticoid Receptor Antagonist (Add if Still Symptomatic)

Add spironolactone for patients with NYHA Class III-IV heart failure who remain symptomatic despite ACE inhibitor and beta-blocker therapy. 1, 5

• Spironolactone reduces mortality and hospitalizations in advanced heart failure 1, 4
• Initiation protocol: Start with low-dose (12.5-25 mg daily), check serum potassium and creatinine after 5-7 days, then titrate accordingly 1
• Potassium monitoring: If K+ rises to 5.0-5.5 mmol/L, reduce dose by 50%; stop if K+ >5.5 mmol/L 2
• Recheck potassium every 5-7 days until values are stable 1

Advanced Therapy: Sacubitril/Valsartan

Consider replacing the ACE inhibitor with sacubitril/valsartan in ambulatory patients who remain symptomatic despite optimal therapy with ACE inhibitor, beta-blocker, and MRA. 1, 5

• Sacubitril/valsartan further reduces heart failure hospitalization and death compared to ACE inhibitors alone 1, 5

Alternative Agents (If ACE Inhibitors Not Tolerated)

If ACE inhibitors cause intractable cough or angioedema, substitute an angiotensin receptor blocker (ARB). 1

If neither ACE inhibitors nor ARBs are tolerated, use the combination of hydralazine and isosorbide dinitrate. 1, 6

Critical Medications to Avoid

Do NOT prescribe these medications in patients with HFrEF: 1, 2

• Calcium channel blockers (diltiazem, verapamil): Increase risk of heart failure worsening and hospitalization due to negative inotropic effects
• NSAIDs or COX-2 inhibitors: Increase risk of heart failure worsening, hospitalization, and renal dysfunction
• Thiazolidinediones (glitazones): Increase risk of heart failure worsening and hospitalization
• Triple neurohormonal blockade (ACE inhibitor + ARB + MRA): Increases risk of renal dysfunction and hyperkalemia

Non-Pharmacological Management

Provide comprehensive patient education covering: 1, 2

• What heart failure is and why symptoms occur
• How to recognize worsening symptoms (increased dyspnea, weight gain, edema)
• When to seek immediate medical attention

Daily self-monitoring: 1, 2

• Daily weight monitoring: Weigh after waking, before dressing, after voiding, before eating
• Instruct patients to increase diuretic dose and contact healthcare team if weight increases >1.5-2.0 kg over 2 consecutive days

Dietary modifications: 1, 2

• Sodium restriction: Limit to 2-3 grams daily, particularly in severe heart failure
• Avoid excessive fluid intake in severe heart failure
• Avoid excessive alcohol consumption

Physical activity: 1, 5

• Encourage regular aerobic exercise in stable patients to improve functional capacity, reduce symptoms, and decrease hospitalization risk
• Rest is not encouraged in stable conditions; daily physical activity prevents muscle deconditioning

Smoking cessation: 1

• Strongly advise refrain from smoking; nicotine replacement therapies are acceptable

Device Therapy Considerations

Implantable cardioverter-defibrillator (ICD) is indicated for: 1, 2, 5

• Patients with symptomatic HF (NYHA Class II-III), LVEF ≤35%, and optimal medical therapy for ≥3 months
• Patients who have survived ventricular arrhythmia causing hemodynamic instability
• Do NOT implant ICD within 40 days of myocardial infarction (does not improve prognosis during this period) 1, 5

Cardiac resynchronization therapy (CRT) is indicated for: 1, 2

• Symptomatic patients in sinus rhythm with QRS duration ≥150 msec, left bundle branch block (LBBB) morphology, and LVEF ≤35% despite optimal medical therapy

Common Pitfalls to Avoid

• Do not use diuretics as monotherapy for long-term management, as they activate the renin-angiotensin-aldosterone system and worsen neurohormonal activation 6
• Do not withhold ACE inhibitors and beta-blockers during hospitalization unless the patient is hemodynamically unstable (systolic BP <90 mmHg) or in cardiogenic shock 2
• Do not use inotropic agents (dobutamine, milrinone) unless the patient has cardiogenic shock with both pulmonary congestion AND peripheral hypoperfusion, as they increase mortality 1
• Do not delay beta-blocker initiation waiting for "perfect" compensation; start once the patient is stable on ACE inhibitor therapy 1