What is the optimal management plan for a patient with a recent hospitalization for congestive heart failure (CHF), ongoing symptoms, and impaired ejection fraction, who is currently on an Angiotensin-Converting Enzyme (ACE) inhibitor and a beta blocker, and following a low-sodium diet?

Optimal Management for Recent CHF Hospitalization with Ongoing Symptoms

Add an SGLT2 inhibitor and spironolactone immediately, uptitrate your ACE inhibitor and beta-blocker to target doses, optimize diuretics to achieve euvolemia, and ensure close follow-up within 1-2 weeks of discharge. 1, 2

Immediate Medication Optimization

Continue and Uptitrate Current Therapy

• Continue the ACE inhibitor and beta-blocker during and after hospitalization unless hemodynamically unstable 1
• Uptitrate both medications to evidence-based target doses used in mortality trials (e.g., enalapril 10-20 mg twice daily, lisinopril 30-35 mg once daily, or ramipril 10 mg once daily for ACE inhibitors; bisoprolol 10 mg daily, carvedilol 25-50 mg twice daily, or metoprolol CR/XL 200 mg daily for beta-blockers) 1, 2
• Higher ACE inhibitor doses reduce death or hospitalization more than lower doses—aim for target doses, not just "some dose" 1, 3
• Double medication doses at 2-week intervals until reaching target or maximum tolerated dose 1

Add Third and Fourth Medications

• Add spironolactone (mineralocorticoid receptor antagonist) for NYHA class III-IV symptoms—this prevents 57 deaths per 1000 patient-years, the highest mortality benefit among CHF medications 2
• Start spironolactone 12.5-25 mg once daily and monitor potassium closely (acceptable up to 5.5 mmol/L) 1, 2
• Optimize loop diuretic dosing to achieve euvolemia (no peripheral edema, normal jugular venous pressure, no pulmonary congestion) before or during ACE inhibitor/beta-blocker uptitration 1, 2

Consider ARNI (Sacubitril-Valsartan)

• Switch from ACE inhibitor to sacubitril-valsartan if ejection fraction remains reduced despite optimal medical therapy 4
• Allow 36-hour washout period between stopping ACE inhibitor and starting sacubitril-valsartan 4
• Start at 49/51 mg twice daily and uptitrate to target dose of 97/103 mg twice daily after 2-4 weeks 4

Diuretic Management for Ongoing Symptoms

Assess Volume Status

• Measure daily weights at the same time each morning (after waking, before dressing, after voiding, before eating) 1
• Examine for elevated jugular venous pressure, peripheral edema, ascites, and pulmonary congestion 1
• Monitor fluid intake/output and vital signs including supine and standing blood pressure 1

Intensify Diuretics if Congestion Persists

• If inadequate diuresis despite clinical congestion, use one of three strategies: (1) increase loop diuretic dose, (2) add second diuretic (metolazone, spironolactone, or IV chlorothiazide), or (3) switch to continuous IV loop diuretic infusion 1
• For patients already on oral loop diuretics, the initial IV dose should equal or exceed their chronic oral daily dose 1
• Transition from IV to oral diuretics carefully before discharge, monitoring for hypotension, worsening renal function, and recurrent symptoms 1

Beta-Blocker Initiation Timing

When to Start or Restart Beta-Blockers

• Initiate beta-blockers only after achieving euvolemia and discontinuing IV diuretics, vasodilators, and inotropes 1
• Do not start beta-blockers during acute decompensation or within 4 weeks of hospitalization for worsening CHF 1, 2
• Start at low doses (bisoprolol 1.25 mg daily, carvedilol 3.125 mg twice daily, or metoprolol CR/XL 12.5-25 mg daily) in stable patients only 1

Managing Beta-Blocker Side Effects

• If worsening congestion occurs during uptitration, double the diuretic dose first before reducing beta-blocker dose 1, 2
• If marked fatigue or bradycardia (<50 bpm with symptoms), halve beta-blocker dose 1
• Never stop beta-blockers abruptly due to rebound risk of myocardial ischemia and arrhythmias 1

Monitoring During Medication Titration

ACE Inhibitor Monitoring

• Check blood chemistry (creatinine, potassium, blood urea nitrogen) before starting, 1-2 weeks after initiation, and after each dose increase 1, 2
• Accept creatinine increases up to 50% above baseline or to 3 mg/dL (266 μmol/L), whichever is greater 1, 2
• Accept potassium up to 5.5 mmol/L 1, 2
• If creatinine or potassium rise excessively, stop nephrotoxic drugs (NSAIDs), reduce potassium supplements, and reduce diuretic dose if no congestion present 1

Beta-Blocker Monitoring

• Check blood chemistry 1-2 weeks after initiation and after final dose titration 1, 2
• Monitor heart rate, blood pressure, and clinical status (symptoms, signs of congestion, body weight) at each visit 1
• Asymptomatic hypotension does not require treatment changes 1

Spironolactone Monitoring

• Monitor potassium closely—seek specialist advice if potassium rises to 6.0 mmol/L 1
• Check renal function regularly, especially when combined with ACE inhibitor 1

Discharge Planning and Follow-Up

Comprehensive Discharge Instructions

• Provide written instructions emphasizing: (1) low-sodium diet, (2) discharge medications with focus on adherence and uptitration plans, (3) activity level, (4) follow-up appointments, (5) daily weight monitoring, and (6) what to do if symptoms worsen 1
• Instruct patient to increase diuretic dose if weight increases persistently (2 days) by 1.5-2.0 kg 1

Early Follow-Up

• Schedule follow-up within 1-2 weeks of discharge to assess volume status, medication tolerance, and laboratory values 1
• Use post-discharge care systems if available to facilitate transition to outpatient care 1
• Consider specialist heart failure nurse involvement for patient education and dose uptitration support 1

Critical Cautions

When to Seek Specialist Advice

• Creatinine >2.5 mg/dL (221 μmol/L), potassium >5.0 mmol/L, or symptomatic hypotension (systolic BP <90 mmHg) before starting ACE inhibitor 1, 2
• NYHA class IV with severe decompensation, heart rate <60 bpm, or persistent signs of congestion before starting beta-blocker 1, 2
• Potassium rises to 6.0 mmol/L or creatinine increases by 100% or above 4 mg/dL (354 μmol/L) during treatment 1

Common Pitfalls to Avoid

• Do not use inadequate "maintenance doses" of ACE inhibitors and beta-blockers—uptitrate to target doses used in clinical trials 1, 3
• Do not stop beta-blockers abruptly even if symptoms worsen—adjust other medications first 1
• Do not withhold ACE inhibitors or beta-blockers during hospitalization unless hemodynamically unstable 1
• Do not delay adding spironolactone in patients with persistent NYHA class III-IV symptoms despite ACE inhibitor and beta-blocker 2