What are the symptoms and treatment options for Congestive Heart Failure (CHF)?

From the Guidelines

Congestive heart failure patients should be treated with a combination of lifestyle changes and medications, including ACE inhibitors or ARBs, beta-blockers, and diuretics, to reduce morbidity, mortality, and improve quality of life, as recommended by the 2016 ESC guidelines 1.

Treatment Approach

The treatment approach for congestive heart failure (CHF) involves a combination of lifestyle changes and medications. Patients should limit sodium intake to 2,000 mg daily, restrict fluid intake to 1.5-2 liters per day, weigh themselves daily to monitor fluid retention, and engage in regular, moderate exercise as tolerated.

Medications

First-line medications include:

• ACE inhibitors (like lisinopril 10-40 mg daily) or ARBs (such as losartan 25-100 mg daily) to reduce strain on the heart
• Beta-blockers (metoprolol succinate 25-200 mg daily) to slow heart rate
• Diuretics (furosemide 20-80 mg daily) to reduce fluid buildup For moderate to severe CHF, aldosterone antagonists (spironolactone 25-50 mg daily) may be added. SGLT2 inhibitors (dapagliflozin 10 mg daily) have shown benefit regardless of diabetes status.

Key Recommendations

• Diuretics are recommended to improve symptoms and exercise capacity in patients with signs and/or symptoms of congestion 1
• Sacubitril/valsartan is recommended as a replacement for an ACE-I to further reduce the risk of HF hospitalization and death in ambulatory patients with HFrEF 1
• Ivabradine should be considered to reduce the risk of HF hospitalization or cardiovascular death in symptomatic patients with LVEF ≤35% 1

Patient Advice

Patients should be advised to:

• Report deterioration in symptoms, such as tiredness, fatigue, and breathlessness
• Weigh themselves daily and increase their diuretic dose if their weight increases persistently by >1.5-2.0 kg
• Avoid NSAIDs not prescribed by a physician and salt substitutes high in K+
• Report principal adverse effects, such as dizziness/symptomatic hypotension and cough

Regular Follow-up

Regular follow-up with healthcare providers is essential to monitor medication effectiveness and adjust treatment as needed. This approach can help reduce morbidity, mortality, and improve quality of life for patients with congestive heart failure.

From the FDA Drug Label

The Systolic Heart Failure Treatment with the I f Inhibitor Ivabradine Trial (SHIFT) was a randomized, double-blind trial comparing ivabradine and placebo in 6,558 adult patients with stable New York Heart Association (NYHA) class II to IV heart failure, left ventricular ejection fraction ≤ 35%, and resting heart rate ≥ 70 bpm SHIFT demonstrated that ivabradine reduced the risk of the combined endpoint of hospitalization for worsening heart failure or cardiovascular death based on a time-to-event analysis (hazard ratio: 0.82,95% confidence interval [CI]: 0.75,0.90, p < 0. 0001) The treatment effect reflected only a reduction in the risk of hospitalization for worsening heart failure; there was no favorable effect on the mortality component of the primary endpoint.

Ivabradine reduces the risk of hospitalization for worsening heart failure in patients with congestive heart failure, as demonstrated by the SHIFT trial 2.

• The study showed a hazard ratio of 0.82 for the combined endpoint of hospitalization for worsening heart failure or cardiovascular death.
• Key benefits of ivabradine include reducing the risk of hospitalization for worsening heart failure.
• However, no favorable effect was observed on the mortality component of the primary endpoint.

From the Research

Definition and Treatment of Congestive Heart Failure

• Congestive heart failure (CHF) is a condition where the heart is unable to pump enough blood to meet the body's needs, leading to symptoms such as shortness of breath, fatigue, and swelling in the legs and feet.
• The treatment of CHF typically involves a combination of medications, lifestyle changes, and possibly surgery or other interventions.

Medications for Congestive Heart Failure

• ACE inhibitors, such as lisinopril, are commonly used to treat CHF, as they have been shown to improve symptoms and reduce mortality 3, 4.
• Other medications that may be used to treat CHF include diuretics, digitalis, and beta blockers.
• The use of quadruple therapy, including an ACE inhibitor, a beta blocker, a diuretic, and a mineralocorticoid receptor antagonist, has been shown to be effective in reducing mortality and morbidity in patients with CHF 5.

Benefits and Risks of High-Dose Lisinopril

• High doses of lisinopril (32.5 to 35mg daily) have been shown to be more effective than low doses (2.5 to 5mg daily) in reducing the risk of major clinical events, including death and hospitalization, in patients with CHF 3.
• However, high doses of lisinopril may also increase the risk of adverse events, such as hypotension and worsening renal function, although these events can often be managed by adjusting the dose or concomitant medications.

Combination Therapy for Congestive Heart Failure

• Combination therapy, including the use of vasodilators and inotropic agents, may be effective in improving cardiac function in patients with CHF 6.
• The use of ACE inhibitors, such as lisinopril, in combination with other medications, such as diuretics and digitalis, has been shown to be effective in improving symptoms and reducing mortality in patients with CHF 3, 7.

Initial Therapy for Systolic Heart Failure

• Initial pharmacotherapy for systolic heart failure should consist of maximal tolerated dosages of ACE inhibitors, with the addition of other medications, such as beta blockers and diuretics, as needed 7.
• The use of angiotensin II receptor blockers (ARBs) may be considered in patients who are intolerant of ACE inhibitors, although they may not provide the same level of survival benefit 7.