Management of Heart Failure
Foundational Pharmacological Therapy
All patients with heart failure and reduced ejection fraction (HFrEF) should be rapidly initiated on four foundational medication classes—ACE inhibitors/ARBs/ARNI, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors—ideally within the first 3 months of diagnosis, with titration to target doses over 2-4 weeks, not sequentially over months. 1
Medication Algorithm for HFrEF
First-line therapy: Initiate ARNI (sacubitril/valsartan) for NYHA class II-III patients, as it is preferred over ACE inhibitors for mortality reduction 2. If ARNI is not tolerated due to cough or angioedema, use ACE inhibitors; if ACE inhibitors cause hypotension or renal insufficiency, use ARBs 3.
Beta-blockers: Start evidence-based beta-blockers (carvedilol, metoprolol succinate, or bisoprolol) in all HFrEF patients unless contraindicated, continuing even during hospitalization unless hemodynamically unstable 2, 1. These reduce mortality and hospitalizations 3.
Mineralocorticoid receptor antagonists: Add spironolactone or eplerenone for patients with NYHA class II-IV symptoms and LVEF ≤35%, monitoring potassium and renal function closely to avoid hyperkalemia 2, 3.
SGLT2 inhibitors: Initiate dapagliflozin or empagliflozin for all symptomatic chronic HFrEF patients regardless of diabetes status, as they reduce hospitalization and cardiovascular mortality 2, 1. SGLT2 inhibitors are also recommended across the entire ejection fraction spectrum, including HFpEF 1.
Symptomatic Management with Diuretics
Loop diuretics (furosemide) are essential when fluid overload manifests as pulmonary congestion or peripheral edema 2, 3. Administer IV loop diuretics at doses equal to or exceeding chronic oral daily dose within 1 hour of acute decompensation presentation 1.
If no initial response, double the loop diuretic dose up to furosemide 500 mg equivalent 2. Add thiazide-type diuretics to loop diuretics for resistant cases 2.
Use diuretics cautiously to avoid excessive diuresis, which can worsen renal function and hypotension 3. Teach patients flexible diuretic regimen based on daily weight monitoring 1.
Digoxin may be added at any time to reduce symptoms and enhance exercise tolerance, particularly for rate control in patients with atrial fibrillation and rapid ventricular rates 3, 2.
Device Therapy Indications
Implantable cardioverter-defibrillator (ICD): Recommend for primary prevention in patients with LVEF ≤30-35%, NYHA class II-III on optimal medical therapy for ≥3 months, and life expectancy >1 year 1, 2.
Cardiac resynchronization therapy (CRT): Recommend for patients with LVEF ≤35%, sinus rhythm, left bundle branch block (LBBB), QRS duration ≥150 ms, and NYHA class II-IV symptoms 1, 2.
Lifestyle Modifications
Dietary Interventions
Sodium restriction: Limit sodium intake to <2-3 g/day (reasonable for symptomatic HF patients to reduce congestive symptoms) 1, 3. Moderate salt restriction is better than strict reduction 4.
DASH diet: Recommend high intakes of fruits, vegetables, low-fat dairy, and whole grains, which effectively reduces blood pressure and prevents HF 3.
Mediterranean diet: Emphasize high consumption of olive oil (≥4 tbsp/day), tree nuts (≥3 servings/week), fresh fruits (≥3 servings/day), vegetables (≥2 servings/day), fish (≥3 servings/week), legumes (≥3 servings/week), and white meat instead of red meat 3. Discourage soda drinks, commercial bakery goods, and processed meats 3.
Fluid restriction: Evidence for fluid restriction is limited and conflicting 5. Reasonable sodium restriction is preferred over strict fluid limits 3.
Alcohol: Avoid excessive alcohol intake, and abstain completely in alcohol-induced cardiomyopathy 3, 1.
Exercise and Physical Activity
Exercise training is safe and effective for patients with HF who are able to participate, improving functional status, exercise tolerance, health-related quality of life, and reducing HF hospitalization rates 3. This applies to both HFrEF and HFpEF patients 3.
Recommend regular physical activity in stable patients to prevent muscle deconditioning, except during periods of acute decompensation or suspected myocarditis 3.
Refer to structured exercise programs when appropriate, recognizing physical and functional limitations such as frailty and comorbidities 3.
Weight and Smoking
Weight management: Maintain healthy body weight 3. The evidence for intentional weight loss in obese HF patients is limited and shows no significant benefit in small studies 6.
Smoking cessation: Stop smoking and taking recreational substances, with referral for specialist advice for smoking cessation and nicotine replacement therapy 3.
Management of Heart Failure with Preserved Ejection Fraction (HFpEF)
SGLT2 inhibitors are recommended for HFpEF with proven benefit 1, 2.
Blood pressure control: Optimize blood pressure control to target <130/80 mmHg if cardiovascular risk >10% 1.
Diuretics: Use cautiously for fluid overload, avoiding excessive diuresis as diastolic dysfunction is highly preload-dependent 1.
Beta-blockers: Consider to lower heart rate and increase diastolic filling period 1.
ACE inhibitors: Consider to improve relaxation, reduce hypertrophy, and control hypertension 1.
Monitoring and Follow-Up
Daily weight monitoring: Instruct patients to measure weight daily at the same time, with increases of 2-3 pounds in 1-2 days prompting contact with healthcare provider 1.
Regular monitoring: At each visit, assess symptoms, weight, blood pressure, heart rate, volume status, renal function, electrolytes, and LVEF 2, 1. Consider natriuretic peptides (BNP or NT-proBNP) at baseline to guide therapy 1.
Post-discharge follow-up: Schedule follow-up within 7-14 days of discharge and telephone contact within 3 days 1, 2. Early physician follow-up reduces 30-day readmission 3.
Multidisciplinary disease-management programs: Implement for high-risk patients to improve quality of life, reduce readmissions, and decrease costs 1, 2.
Patient Education and Self-Care
Patient education should explain HF mechanism, symptom recognition (dyspnea, fatigue, edema), self-weighing technique, medication adherence, and when to seek help 1.
Involve family and carers in HF management and self-care 3.
Provide information on timing of diuretics to optimize sleep, travel preparation according to physical capacity, and awareness of adverse reactions to sun exposure with certain medications (such as amiodarone) 3.
Recognize that depressive symptoms and cognitive dysfunction are more frequent in HF patients and may affect adherence; refer for psychological support when necessary 3.
Advanced Heart Failure (Stage D)
Referral for advanced therapies: Refer patients with advanced HF who wish to prolong survival to a HF specialty team for review of management, assessment for durable mechanical circulatory support (LVAD), cardiac transplantation, and palliative care 1.
Meticulous fluid control: Control fluid retention carefully in end-stage HF, as patients may tolerate only small doses of neurohormonal antagonists or may not tolerate them at all due to risk of hypotension and renal insufficiency 1.
Critical Pitfalls to Avoid
Never use calcium channel blockers as treatment for HF, as they worsen outcomes 1.
Never use long-term intermittent positive inotropic therapy, as it increases mortality 3, 1.
Avoid routine nutritional supplements (coenzyme Q10, carnitine) or hormonal therapies, as they lack evidence 1.
Do not add ARB to ACE inhibitor plus beta-blocker combination, as this increases adverse events without clear benefit 1.
Avoid abrupt discontinuation of beta-blockers, as this can lead to rebound tachycardia and worsening HF 7.