Heart Failure Management

Medication Therapy

The European Society of Cardiology recommends starting with dapagliflozin 10mg daily or empagliflozin 10mg daily for patients with heart failure, with minimal impact on blood pressure, even in patients with low blood pressure 1
Consider metoprolol succinate or bisoprolol instead of carvedilol for better tolerability, and target heart rate <70 bpm if possible, as recommended by the European Society of Cardiology 1
Loop diuretics (e.g., furosemide) are recommended as first-line for congestion, and for refractory congestion, consider higher doses of loop diuretics, addition of a second diuretic (metolazone, spironolactone), or continuous infusion of loop diuretic, as recommended by the American College of Cardiology 2

The following medications are recommended for heart failure:

Medication	Initial Dose	Target Dose
Sacubitril/Valsartan	49/51 mg twice daily	97/103 mg twice daily
Lisinopril	2.5-5 mg once daily	20-40 mg once daily
Enalapril	2.5 mg twice daily	10-20 mg twice daily
Ramipril	1.25-2.5 mg once daily	10 mg once daily
Candesartan	4-8 mg once daily	32 mg once daily
Bisoprolol	1.25 mg once daily	10 mg once daily
Carvedilol	3.125 mg twice daily	25-50 mg twice daily
Metoprolol succinate	12.5-25 mg once daily	200 mg once daily
Spironolactone	12.5-25 mg once daily	25-50 mg once daily
Eplerenone	25 mg once daily	50 mg once daily
Dapagliflozin	10 mg once daily	-
Empagliflozin	10 mg once daily	-

3, 4, 5, 6

A forced-titration strategy should be followed to increase doses progressively at 2-4 week intervals, targeting the maximum tolerated dose of each agent, and therapy should not be discontinued prematurely due to asymptomatic changes in vital signs or lab values, as recommended by the European Society of Cardiology 7
Quadruple therapy with SGLT2 inhibitors, beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists is recommended to significantly reduce mortality and hospitalizations in patients with HFrEF, as recommended by the European Society of Cardiology 5, 8, 3, 9
SGLT2 inhibitors provide mortality benefit regardless of diabetes status in patients with heart failure, as recommended by the American College of Cardiology 2
Ivabradine can be used for patients in sinus rhythm who cannot tolerate beta-blockers or have HR >70 bpm despite maximum tolerated beta-blocker dose, as recommended by the European Society of Cardiology 1
Digoxin can be used for rate control in patients with atrial fibrillation who cannot tolerate beta-blockers, as recommended by the European Society of Cardiology 1
ACE inhibitors, such as Lisinopril, Enalapril, or Ramipril, are recommended as first-line treatment for patients with heart failure and reduced ejection fraction (HFrEF) to improve outcomes and lower blood pressure in hypertensive patients with HFrEF, with a modest mortality benefit of 5-16% risk reduction, as recommended by the European Society of Cardiology and American Heart Association 10, 7
Beta-blockers, such as Carvedilol, Metoprolol succinate, or Bisoprolol, are recommended to reduce mortality and improve symptoms in moderate-to-severe heart failure, with at least 20% reduction in mortality risk, as recommended by the European Society of Cardiology and American Heart Association 11, 7
Alternative options for patients who cannot tolerate ACE inhibitors include ARBs, such as Candesartan, which can be used as an alternative to ACE inhibitors, as recommended by the European Society of Cardiology and American Heart Association 10, 12
Sacubitril/valsartan is recommended as a replacement for an ACE-I or ARB in patients with HFrEF to reduce the risk of HF hospitalization and of cardiovascular and all-cause death, as recommended by the European Society of Cardiology and American College of Cardiology 13, 8

Interventional Options

Evaluate for transcatheter edge-to-edge repair (TEER) if symptoms persist despite optimal medical therapy, as recommended by the European Society of Cardiology 1
Cardiac resynchronization therapy (CRT) should be considered for patients with QRS duration ≥150 msec and LBBB morphology, as it can significantly improve ejection fraction in appropriate candidates, as recommended by the European Society of Cardiology and American College of Cardiology 14, 15, 16, 13
Implantable cardioverter-defibrillator (ICD) is recommended for patients with LVEF ≤35% despite ≥3 months of optimal medical therapy (with expected survival >1 year), as recommended by the European Society of Cardiology and American College of Cardiology 16, 17, 13

Patient Evaluation and Follow-up

Refer to advanced heart failure team for evaluation of persistent symptoms despite optimal medical therapy, potential candidacy for advanced therapies, and palliative care options, as suggested by the American Heart Association 3
Close follow-up every 2-4 weeks during medication titration is recommended, with monitoring of symptoms, functional status, blood pressure, heart rate, renal function, electrolytes, and volume status with daily weight monitoring 1
Regular assessment of volume status and symptoms is recommended for patients with heart failure, as recommended by the European Society of Cardiology and American College of Cardiology 18
Daily weight monitoring should be performed, with an action plan in place for weight gain greater than 2 kg in 3 days, as recommended by the European Society of Cardiology and American College of Cardiology 19, 20, 21

Lifestyle Modifications

Patients with heart failure should be encouraged to engage in regular physical activity, with a structured aerobic exercise program starting with low intensity, and avoiding heavy labor, as recommended by the European Society of Cardiology and American College of Cardiology 22, 23, 24, 16, 21, 25
Moderate sodium restriction should be implemented to reduce fluid retention, with a goal of achieving optimal volume status and reducing hospitalizations, as recommended by the European Society of Cardiology and American College of Cardiology 22, 23, 24, 26, 25
Smoking cessation is recommended for all patients with heart failure, and alcohol consumption should be limited to moderate intake (1-2 glasses of wine/day), as recommended by the European Society of Cardiology and American College of Cardiology 26, 23, 25

Prognosis and Palliative Care

Patients with severely reduced ejection fraction (15%) have higher mortality risk and may benefit from early palliative care discussions, according to the American Heart Association 3
Heart failure management involves a multidisciplinary team approach, comprehensive education, and seamless transition of care from primary to tertiary levels, as recommended by the European Society of Cardiology 1, 27
Goals of care discussions should be conducted, as recommended by the American College of Cardiology 8

Contraindications and Precautions

The European Society of Cardiology advises against the use of NSAIDs and COX-2 inhibitors in all heart failure patients due to increased risk of worsening heart failure, as recommended by the European Society of Cardiology 16
The European Society of Cardiology recommends avoiding thiazolidinediones (glitazones) in heart failure patients due to increased risk of worsening heart failure, as recommended by the European Society of Cardiology 16
The European Society of Cardiology warns against combining ARB with ACE inhibitor and MRA due to increased risk of renal dysfunction and hyperkalemia, as recommended by the European Society of Cardiology 16
Diltiazem/verapamil should be avoided in HFrEF patients as they increase risk of worsening heart failure, but can be used in HFpEF patients with caution, particularly for rate control in atrial fibrillation, as recommended by the American College of Cardiology and European Society of Cardiology 28, 29, 16
In cases of hyperkalemia (>5.5 mEq/L), reduce or temporarily discontinue RAAS inhibitors, intensify diuretic therapy if volume overloaded, and consider patiromer for persistent hyperkalemia in patients who would benefit from RAAS inhibitors, according to the American Journal of Kidney Diseases 30