What is the recommended treatment for acute decompensated heart failure (ADHF) and chronic heart failure (CHF), including heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF)?

Treatment of Heart Failure (HF), Acute Decompensated Heart Failure (ADHF), and Chronic Heart Failure (CHF)

Chronic Heart Failure with Reduced Ejection Fraction (HFrEF)

For patients with HFrEF (LVEF ≤40%), initiate and uptitrate four foundational medication classes to target doses to reduce mortality and hospitalization: SGLT2 inhibitors, ARNI (sacubitril/valsartan), beta-blockers, and mineralocorticoid receptor antagonists (MRA). 1

Core Pharmacotherapy (Guideline-Directed Medical Therapy - GDMT)

• ACE inhibitors (ACE-I) or ARNI are recommended in addition to beta-blockers for all symptomatic HFrEF patients to reduce HF hospitalization and death 2

• Sacubitril/valsartan (ARNI) should replace ACE-I in ambulatory patients who remain symptomatic despite optimal treatment with ACE-I, beta-blocker, and MRA to further reduce HF hospitalization and death 2

• Beta-blockers are recommended in addition to ACE-I for all stable, symptomatic HFrEF patients to reduce HF hospitalization and death 2

• Mineralocorticoid receptor antagonists (MRA) are recommended for patients who remain symptomatic despite ACE-I and beta-blocker treatment to reduce HF hospitalization and death 2

• SGLT2 inhibitors are recommended as part of the foundational four-drug regimen to reduce mortality and hospitalization 1

• Diuretics are recommended to improve symptoms and exercise capacity in patients with signs or symptoms of congestion 2

Critical Medication Management Principles

• Never discontinue GDMT medications when LVEF improves above 40%, as patients remain at high risk for relapse 1

• Do not withhold beta-blockers during acute decompensation unless there is marked volume overload or recent initiation, as withholding worsens outcomes 1

• Continue evidence-based beta-blockers throughout dialysis in patients requiring renal replacement therapy, as they reduce mortality by at least 20% and sudden cardiac death 3

Medications to Avoid

• Diltiazem or verapamil are not recommended in HFrEF patients, as they increase the risk of HF worsening and hospitalization 2

• Do not add an ARB (or renin inhibitor) to the combination of ACE-I and MRA due to increased risk of renal dysfunction and hyperkalemia 2

Heart Failure with Mildly Reduced Ejection Fraction (HFmrEF)

• SGLT2 inhibitors, ARNI, ACE inhibitors, ARBs, MRA, and beta-blockers are recommended for HFmrEF treatment 1

Heart Failure with Preserved Ejection Fraction (HFpEF)

• SGLT2 inhibitors are recommended as first-line therapy for HFpEF 1

• Treatment of hypertension, MRA, ARNI, and ARBs are recommended for HFpEF management 1

Acute Decompensated Heart Failure (ADHF)

Initial Assessment and Diagnosis

• Immediate ECG and echocardiography are recommended in all patients with suspected cardiogenic shock 2

• Measure plasma natriuretic peptides (BNP, NT-proBNP, or MR-proANP) upon presentation to the emergency department in all patients with acute dyspnea to differentiate AHF from non-cardiac causes (thresholds: BNP < 100 pg/mL, NT-proBNP < 300 pg/mL, MR-proANP < 120 pg/mL make AHF unlikely) 2

• Early echocardiography should be performed in all patients with de novo AHF and those with unknown cardiac function, preferably within 48 hours of admission 2

• Laboratory assessments at admission should include cardiac troponin, BUN/urea, creatinine, electrolytes (sodium, potassium), liver function tests, and TSH in newly diagnosed AHF 2

Acute Management Strategies

Immediate IV loop diuretics at doses equal to or exceeding chronic oral daily dose are recommended for patients with signs or symptoms of congestion 1

• Diuretics should be given as intermittent boluses or continuous infusion, with dose and duration adjusted according to symptoms and clinical status 2

• For patients on chronic diuretic therapy, initial IV dose should be at least equivalent to oral dose 2

• Monitor creatinine, BUN, and electrolytes every 1-2 days while hospitalized and before discharge 2

Continuation of Chronic Therapies

• In worsening chronic HFrEF, continue evidence-based disease-modifying therapies in the absence of hemodynamic instability or contraindications 2

• Continue beta-blockers and RAAS inhibitors unless marked volume overload or recent initiation is present 1

• Monitor daily weights, electrolytes, and renal function during aggressive diuresis 1

Inotropic Agents and Advanced Support

• Inotropic agents are not recommended unless the patient is symptomatically hypotensive or hypoperfused due to safety concerns 2

• All patients with cardiogenic shock should be rapidly transferred to a tertiary care center with 24/7 cardiac catheterization services and dedicated ICU/CCU with availability of short-term mechanical circulatory support 2

Hemodynamic Targets

• The primary therapeutic target is reduction of left ventricular filling pressure, as persistently elevated filling pressure predicts increased risk of fatal decompensation and sudden death 4

• Vasodilators have a more compelling physiologic rationale than inotropic agents for reducing pulmonary wedge pressure and promoting balanced arterial and venous dilation 4

Device Therapy

Implantable Cardioverter-Defibrillator (ICD)

• ICD is recommended for secondary prevention in patients who have recovered from ventricular arrhythmia causing hemodynamic instability and are expected to survive >1 year with good functional status 2

• ICD is recommended for primary prevention in symptomatic HF (NYHA Class II-III) patients with LVEF ≤35% despite ≥3 months of optimal medical therapy, expected to survive substantially longer than 1 year with good functional status, who have ischemic heart disease (unless MI within prior 40 days) or dilated cardiomyopathy 2, 1

• ICD implantation is not recommended within 40 days of MI, as implantation at this time does not improve prognosis 2

Cardiac Resynchronization Therapy (CRT)

• CRT is recommended for symptomatic HF patients in sinus rhythm with QRS duration ≥150 msec and LBBB morphology with LVEF ≤35% despite optimal medical therapy to improve symptoms and reduce morbidity and mortality 2, 1

• CRT is recommended for QRS duration 130-149 msec with LBBB morphology and LVEF ≤35% despite optimal medical therapy 2

• CRT rather than RV pacing is recommended for HFrEF patients regardless of NYHA class who have an indication for ventricular pacing 2

• CRT is contraindicated in patients with QRS duration <130 msec 2

Prevention Strategies

• Treatment of hypertension is recommended to prevent or delay the onset of HF and prolong life 2

• ACE-I is recommended in patients with asymptomatic LV systolic dysfunction and history of MI to prevent or delay HF onset and prolong life 2

• Beta-blocker is recommended in patients with asymptomatic LV systolic dysfunction and history of MI to prevent or delay HF onset and prolong life 2

Non-Pharmacological Management

• Regular aerobic exercise is recommended in stable HF patients to improve functional capacity, symptoms, and reduce HF hospitalization risk 2

• Enrollment in a multidisciplinary care management program is recommended to reduce HF hospitalization and mortality 2