Management of New Chronic Heart Failure in Adults
For a new diagnosis of chronic heart failure, immediately obtain natriuretic peptide levels (BNP or NT-proBNP) and arrange urgent echocardiography within 2 weeks to determine ejection fraction, followed by specialist assessment—then initiate guideline-directed medical therapy with ACE inhibitors (or ARNIs) plus beta-blockers as first-line treatment for heart failure with reduced ejection fraction. 1, 2
Initial Diagnostic Evaluation
Immediate Testing Required
- Measure serum natriuretic peptides (BNP or NT-proBNP) to confirm the diagnosis and differentiate heart failure from non-cardiac causes of dyspnea 2, 3
- Obtain ECG and echocardiography urgently (within 2 weeks) to assess structural abnormalities, determine ejection fraction, and identify underlying causes 1, 2
- Arrange specialist assessment by a cardiologist or heart failure specialist within the same timeframe as echocardiography 1
Baseline Laboratory Assessment
- Comprehensive metabolic panel including renal function (creatinine, BUN), electrolytes (sodium, potassium) 2, 3
- Complete blood count, liver function tests, thyroid function tests 3
- Lipid panel and hemoglobin A1c if not recently checked 2
Natriuretic Peptide Interpretation
Use age-specific thresholds for NT-proBNP: >450 pg/mL for age <50 years, >900 pg/mL for age 50-75 years, and >1800 pg/mL for age >75 years 3. Values >2000 pg/mL indicate significantly worse prognosis with increased risk of death or readmission 3.
Pharmacologic Management by Ejection Fraction Category
Heart Failure with Reduced Ejection Fraction (HFrEF: LVEF ≤40%)
Four-Pillar Guideline-Directed Medical Therapy (initiate as early as possible): 2
ACE Inhibitors or ARNIs (first-line): Start ACE inhibitor (or preferably sacubitril-valsartan if appropriate) to reduce mortality and morbidity 1, 2, 3
Beta-Blockers: Initiate bisoprolol, metoprolol succinate, or carvedilol in all patients regardless of age or comorbidities using "start-low, go-slow" approach 1, 2, 3
Mineralocorticoid Receptor Antagonists: Add spironolactone or eplerenone for NYHA class II-IV symptoms to improve survival 1, 2, 3
SGLT2 Inhibitors: Include as part of core therapy given mortality benefit demonstrated in HFrEF 2
Second-Line Options: If symptoms persist despite first-line therapy, consider aldosterone antagonists, ARBs, or combination therapy with nitrate plus hydralazine 1
Heart Failure with Mildly Reduced Ejection Fraction (HFmrEF: LVEF 41-49%)
Evidence from post-hoc analyses suggests drugs effective in HFrEF are also beneficial in HFmrEF 4. Apply the same four-pillar GDMT approach as for HFrEF 2, 4. This category shares more clinical features with HFrEF than HFpEF, particularly high prevalence of ischemic heart disease 4.
Important caveat: LVEF has considerable variability over time (SD 7.4%), and patients with HFmrEF have <25% probability of remaining in this category after 1 year 5. Do not withhold proven HFrEF therapies based solely on borderline ejection fraction measurements 5.
Heart Failure with Preserved Ejection Fraction (HFpEF: LVEF ≥50%)
No specific pharmacologic therapies have consistently improved survival in HFpEF 1, 6. Management focuses on:
- Control of systolic and diastolic hypertension 6
- Ventricular rate control in atrial fibrillation 6
- Judicious use of diuretics for congestion 6
- SGLT2 inhibitors have shown benefit across the entire LVEF spectrum and should be considered 7
Acute Symptom Management
Diuretic Therapy for Congestion
- Administer IV loop diuretics promptly (furosemide 20-40 mg IV or equivalent) to relieve congestion and fluid overload in new-onset heart failure 2, 3
- Monitor daily weight, fluid intake/output, and supine/standing vital signs 3
- Measure serum electrolytes, BUN, and creatinine daily during active diuretic therapy 3
Non-Pharmacologic Management
Exercise and Rehabilitation
Offer group exercise-based rehabilitation programs to all patients with stable symptoms and no contraindications 1. Regular aerobic exercise improves functional capacity, reduces symptoms, and decreases hospitalization risk 2.
Lifestyle Modifications
- Sodium restriction for severe heart failure 2
- Fluid restriction in severe cases 2
- Limit alcohol intake 2
- Enroll in multidisciplinary care management program to reduce hospitalization and mortality 2
Monitoring Strategy
Initial Follow-Up
- Schedule early follow-up visit within 7-14 days after diagnosis or hospital discharge 2
- Monitor renal function and electrolytes 1-2 weeks after each medication dose increment 2
- Reassess at 3 months, then at 6-month intervals 2
Serial Natriuretic Peptide Monitoring
Consider specialist monitoring of BNP/NT-proBNP levels in selected patients, particularly those with problematic medication up-titration or history of hospitalization 1. A reduction >30% indicates good treatment response 3. This approach is cost-effective when used by specialists and reduces heart failure hospitalizations in patients <75 years 1.
Critical Medications to Avoid
- NSAIDs and COX-2 inhibitors: Increase risk of heart failure worsening and hospitalization 2
- Thiazolidinediones: Increase risk of heart failure exacerbation 2
- Inotropic agents: Avoid unless patient is symptomatically hypotensive or hypoperfused due to safety concerns 2
Advanced Therapies for Persistent Symptoms
Device Therapy
- Cardiac resynchronization therapy (CRT): Recommended for symptomatic patients with HFrEF in sinus rhythm with QRS ≥150 ms and LBBB morphology, or QRS 120-149 ms with mechanical dyssynchrony on echocardiography, when LVEF <35% 1, 2
- Implantable cardioverter-defibrillators (ICDs): Consider for patients with sustained ventricular tachycardia, nonsustained VT inducible on EP testing with LVEF <35%, or QRS ≥120 ms with LVEF <30% 1, 2
Refractory Heart Failure
For patients not responding to optimal medical therapy and device therapy, consider mechanical circulatory support, heart transplantation evaluation, or palliative care 2.
Key Implementation Principles
Continue evidence-based disease-modifying therapies even during worsening of chronic HFrEF, unless hemodynamic instability or specific contraindications develop 2. The goal is to initiate all four pillars of GDMT as rapidly as tolerated rather than sequentially 2.
Common pitfall: Telemonitoring showed no consistent benefit in reducing hospital readmission or mortality in large trials, so it is not routinely recommended 1. The observed benefits in some studies may reflect improved access to care rather than the technology itself 1.