What are the treatment guidelines for Heart Failure (HF)?

From the Guidelines

Heart failure treatment should prioritize a comprehensive approach including ACE inhibitors, beta-blockers, and mineralocorticoid receptor antagonists to reduce symptoms, improve quality of life, and extend survival, as recommended by the 2016 ESC guidelines 1. The cornerstone of heart failure treatment with reduced ejection fraction (HFrEF) involves the use of ACE inhibitors (such as lisinopril 10-40mg daily or enalapril 2.5-20mg twice daily) or ARBs (like losartan 25-100mg daily) to reduce afterload and remodeling, in addition to beta-blockers (such as metoprolol succinate 12.5-200mg daily, carvedilol 3.125-25mg twice daily, or bisoprolol 1.25-10mg daily) to reduce heart rate and workload 1. Key considerations in the management of heart failure include:

• The use of mineralocorticoid receptor antagonists like spironolactone (25-50mg daily) or eplerenone (25-50mg daily) for patients with HFrEF who remain symptomatic despite treatment with an ACE inhibitor and a beta-blocker 1.
• The role of diuretics (such as furosemide 20-80mg daily or as needed) in managing fluid overload, although they do not improve survival 1.
• The potential for combination therapy with sacubitril/valsartan (24/26mg to 97/103mg twice daily) in advanced HFrEF as a replacement for ACE inhibitors.
• Non-pharmacological approaches including sodium restriction (<2-3g daily), fluid restriction if needed, regular exercise, smoking cessation, and limiting alcohol.
• The consideration of device therapy (ICDs, CRT) and advanced options like LVAD or transplantation for eligible patients with severe disease. Treatment should be initiated at low doses and titrated gradually while monitoring renal function, electrolytes, and blood pressure, as emphasized in the 2009 ACC/AHA guidelines 1.

From the FDA Drug Label

In trials in patients treated with digitalis and diuretics, treatment with enalapril resulted in decreased systemic vascular resistance, blood pressure, pulmonary capillary wedge pressure and heart size, and increased cardiac output and exercise tolerance. Heart Failure, Mortality Trials In a multicenter, placebo-controlled clinical trial, 2,569 patients with all degrees of symptomatic heart failure and ejection fraction ≤35 percent were randomized to placebo or enalapril and followed for up to 55 months (SOLVD-Treatment) Use of enalapril was associated with an 11 percent reduction in all-cause mortality and a 30 percent reduction in hospitalization for heart failure. Enalapril maleate is indicated for the treatment of symptomatic heart failure, usually in combination with diuretics and digitalis. In the placebo-controlled studies that demonstrated improved survival, patients were titrated as tolerated up to 40 mg, administered in two divided doses.

Heart Failure Treatment Guidelines:

• Enalapril is indicated for the treatment of symptomatic heart failure, usually in combination with diuretics and digitalis.
• The recommended initial dose is 2.5 mg, and the recommended dosing range is 2.5 to 20 mg given twice a day.
• Doses should be titrated upward, as tolerated, over a period of a few days or weeks.
• The maximum daily dose administered in clinical trials was 40 mg in divided doses.
• Enalapril has been shown to reduce mortality and hospitalization for heart failure in patients with symptomatic heart failure and ejection fraction ≤35 percent 2.
• Enalapril can be used in combination with other medications, such as digitalis and diuretics, to treat heart failure 2.

From the Research

Heart Failure Treatment Guidelines

• Heart failure with reduced ejection fraction (HFrEF) treatment strategies include diuretics for symptom relief and quadruple therapy (Angiotensin receptor blocker/neprilysin inhibitors, evidence-based beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter 2 inhibitors) for reduction in hospitalizations, all-cause mortality, and cardiovascular mortality 3.
• Other medications such as intravenous iron, ivabradine, hydralazine/nitrates, and vericiguat may also have a role in certain subgroups of HFrEF patients 3.
• Specific groups of patients with HFrEF may also be candidates for various device therapies such as implanted cardioverter defibrillators, cardiac resynchronization therapy, and trans catheter mitral valve repair 3.

Heart Failure with Preserved Ejection Fraction (HFpEF) Treatment

• Approximately 50% of patients with heart failure have a preserved ejection fraction (HFpEF), and the incidence of HFpEF is increasing relative to HF with reduced ejection fraction (HFrEF) 4.
• Current therapy for HFpEF is largely focused on management of symptoms and comorbidities, with no approved treatments specifically indicated for HFpEF 4, 5.
• Diagnosis of HFpEF in the outpatient setting presents unique challenges due to a high burden of comorbidities and difficulties in distinguishing HFpEF from normal aging 4.
• Treatment strategies for HFpEF include decongestion by diuretics, promotion of a healthy active lifestyle, and management of comorbidities 5.

Initiation/Optimization of HFrEF Medication During Hospitalization

• Current guidelines emphasize the importance of initiating or optimizing the four pillars of HFrEF therapy (beta-blockers, mineralocorticoid receptor antagonists, angiotensin receptor-neprilysin inhibitors, and sodium-glucose cotransporter-2 inhibitors) during hospitalization for acute decompensation 6.
• The initiation or optimization of the four pillars of HFrEF therapy during hospitalization for acute decompensation is feasible and well-tolerated, leading to improvements in clinical parameters and functional status 6.
• Special consideration should be given to renal function when optimizing therapy 6.

Perioperative Implications of HFpEF

• Patients with HFpEF are exquisitely sensitive to the development of hypotension in response to acute declines in LV preload or afterload that may occur during or after surgery 7.
• Anesthesiologists need to be familiar with this heterogeneous and complex clinical syndrome to provide successful care for patients with HFpEF presenting for surgery 7.