From the Guidelines
Congestive heart failure treatment should prioritize guideline-directed medical therapy, including inhibitors of the renin–angiotensin system, neprilysin inhibitors, beta-adrenergic blockers, and mineralocorticoid receptor antagonists, as these have been shown to reduce mortality and improve quality of life 1. The management of patients with chronic heart failure and a reduced ejection fraction requires a multifaceted approach, incorporating medications, lifestyle modifications, and potentially devices or surgery. Key medications include:
- Inhibitors of the renin–angiotensin system, such as ACE inhibitors or ARBs, to reduce strain on the heart
- Neprilysin inhibitors, like sacubitril/valsartan, which have been shown to further reduce the risk of heart failure hospitalization and death in ambulatory patients with symptomatic heart failure with reduced ejection fraction 1
- Beta-adrenergic blockers, such as carvedilol, metoprolol succinate, and bisoprolol, which have been proven to prolong life and reduce the risk of sudden death
- Mineralocorticoid receptor antagonists, which also contribute to a reduction in mortality and sudden death risk Additionally, diuretics are recommended to improve symptoms and exercise capacity in patients with signs and/or symptoms of congestion 1. Lifestyle modifications are crucial and include:
- Sodium restriction
- Fluid restriction if needed
- Regular moderate exercise as tolerated
- Smoking cessation
- Limiting alcohol Daily weight monitoring is important for early detection of fluid retention. For advanced cases, consideration of devices like implantable cardioverter-defibrillators or cardiac resynchronization therapy may be necessary. The goal of these treatments is to reduce the heart's workload, improve pumping efficiency, prevent dangerous arrhythmias, and alleviate symptoms, ultimately enhancing quality of life and survival.
From the FDA Drug Label
In patients whose renal function depends upon the activity of the renin-angiotensin-aldosterone system (e.g., patients with severe congestive heart failure), treatment with ACE inhibitors and angiotensin receptor antagonists has been associated with oliguria, progressive azotemia and, rarely, acute renal failure and death Closely monitor serum creatinine, and down-titrate or interrupt sacubitril and valsartan in patients who develop a clinically significant decrease in renal function
Congestive Heart Failure Treatment: Sacubitril and valsartan can be used to treat congestive heart failure.
- The treatment should be closely monitored, especially in patients with severe congestive heart failure, as it may cause a decrease in renal function.
- Serum creatinine should be closely monitored, and the treatment should be down-titrated or interrupted if a clinically significant decrease in renal function is observed.
- Patients with a history of angioedema, hypotension, or hyperkalemia should be carefully evaluated before starting the treatment.
- The treatment may cause symptomatic hypotension, and patients with an activated renin-angiotensin system are at greater risk.
- Hyperkalemia may occur, and serum potassium should be periodically monitored, especially in patients with risk factors for hyperkalemia 2.
Valsartan can also be used to treat heart failure, and it has been evaluated for safety in several clinical trials.
- In the Valsartan Heart Failure Trial (Val-HeFT), valsartan was compared to placebo, and the incidence of adverse reactions was similar between the two groups 3.
- Valsartan may cause dizziness, hypotension, diarrhea, arthralgia, fatigue, and back pain, and it should be used with caution in patients with renal impairment or hyperkalemia.
From the Research
Treatment Options for Congestive Heart Failure
- The combination of a diuretic and an ACE inhibitor is currently the proper treatment of congestive heart failure, with a beta-blocker added in selected patients 4.
- Angiotensin Converting Enzyme (ACE) inhibitors or Angiotensin Receptor Blockers (ARBs) and Beta Blockers (BB) are recommended for the treatment of HF with a reduced ejection fraction (HFrEF) 5.
- Newer medications such as sacubitril/valsartan, which combines an ARB with a neprilysin inhibitor, have shown benefits in mortality and can be used in place of an ACE inhibitor or an ARB 5.
- Dapagliflozin, a medication targeting the sodium-glucose cotransporter 2 (SGLT2), can be used in addition to current therapies for HFrEF 5.
ACE Inhibitors in Congestive Heart Failure Treatment
- ACE inhibitors have been shown to reduce mortality, reduce hospitalization, reduce symptoms, and increase exercise capacity in patients with heart failure and a large heart (low ejection fraction) 4.
- High doses of ACE inhibitors, such as lisinopril, have demonstrated clinically important advantages over low doses in the treatment of congestive heart failure 6.
- Lisinopril is generally well tolerated by patients with heart failure, with common adverse events including dizziness, headache, hypotension, and diarrhea 6.
Other Treatment Considerations
- Digoxin may be added to improve clinical symptoms, especially in patients with atrial fibrillation 7.
- Aldosterone antagonists may be recommended in select patients with stable New York Heart Association class III or IV heart failure 7.
- Angiotensin receptor blockers (ARBs) may be a suitable replacement for ACE inhibitors due to better tolerability among patients, but their combination may improve outcomes for patients with CHF 8.