Management of Heart Failure at Different Stages

Stage A: At Risk for Heart Failure

The American Academy of Family Physicians recommends treatment should focus on reducing modifiable risk factors, including management of hypertension and hyperlipidemia 1, 2
Diuretic-based antihypertensive therapy has consistently shown to prevent heart failure in a range of patients; ACE inhibitors, angiotensin receptor blockers, and beta blockers are also effective 2
Aggressive treatment of hyperlipidemia with statins reduces the risk of heart failure in at-risk patients 2
Obesity and overweight are repeatedly linked to increased heart failure risk, and diabetes mellitus may triple the risk of heart failure, especially in women 3
Tobacco use is strongly associated with incident heart failure - patients should be strongly advised to quit 3

The American Academy of Family Physicians recommends continuing control of hyperlipidemia and hypertension as in Stage A 3
ACE inhibitors should be used in all patients with reduced ejection fraction to prevent symptomatic heart failure, even without a history of MI 2, 3
For patients with a history of MI or acute coronary syndrome and reduced ejection fraction, ACE inhibitors should be used to prevent symptomatic heart failure and reduce mortality 3
Angiotensin receptor blockers are an alternative for patients who cannot tolerate ACE inhibitors 3
Beta blockers should be used in all patients with reduced ejection fraction to prevent symptomatic heart failure 1, 3
Statins should be used to prevent symptomatic heart failure and cardiovascular events 3

The American Academy of Family Physicians recommends continuing all measures from Stages A and B 1, 3
Diuretics should be used in patients with evidence or history of fluid retention, with monitoring for adverse effects such as electrolyte abnormalities and dehydration 1, 3
ACE inhibitors and beta blockers should be used in all patients with reduced ejection fraction 1
Aldosterone receptor antagonists should be used in patients with NYHA class II through IV heart failure who have an ejection fraction of 35% or less, with monitoring for hyperkalemia and renal insufficiency 3
Sodium restriction may be beneficial for symptom management 3
Exercise training should be considered as an adjunctive approach to improve clinical status in ambulatory patients 4

Before classifying a patient as having refractory heart failure, physicians should confirm the accuracy of the diagnosis, identify and reverse any contributing conditions, and ensure that all conventional medical strategies have been optimally employed 1, 3, 4
Meticulous control of fluid retention is critical in the management of end-stage heart failure 4
Consider specialized treatment strategies, including continuous intravenous positive inotropic therapy and hospice care 4

For hospitalized patients after stabilization, monitor heart rate, rhythm, blood pressure, and oxygen saturation continuously for at least the first 24 hours, and assess symptoms relevant to heart failure daily 5
Measure fluid intake and output, weight, jugular venous pressure, and extent of pulmonary and peripheral edema daily 5
Monitor blood urea nitrogen, creatinine, potassium, and sodium daily during IV therapy and when adjusting medications affecting the renin-angiotensin-aldosterone system 5

Ensure proper diagnosis before initiating treatment - heart failure is largely a clinical diagnosis based on history and physical examination findings 1
When starting ACE inhibitors, review the need for and dose of diuretics and vasodilators, avoid excessive diuresis before treatment, and consider starting treatment in the evening when supine to minimize potential blood pressure effects 1, 6
Patients with advanced heart failure may be less tolerant of neurohormonal antagonism (ACE inhibitors, beta blockers) than those with mild symptoms, as these mechanisms support circulatory homeostasis in advanced disease 4
Before discharge from hospitalization, ensure the acute episode of heart failure has resolved, congestion is absent, a stable oral diuretic regimen has been established for at least 48 hours, and long-term disease-modifying therapy has been optimized 1, 3, 5