Heart Failure Treatment Guidelines

First-Line Medications

The European Society of Cardiology recommends ACE inhibitors as first-line therapy in patients with reduced left ventricular systolic function to reduce mortality and hospitalizations 2, 4
The European Society of Cardiology recommends beta-blockers for all stable patients with mild, moderate, and severe heart failure with reduced ejection fraction (NYHA class II-IV) 1, 3
Diuretics are essential for symptomatic treatment when fluid overload is present, with loop diuretics or thiazides as first-line options, and should always be administered in combination with ACE inhibitors when possible 1, 2, 6

The European Society of Cardiology recommends mineralocorticoid receptor antagonists (MRAs) for patients who remain symptomatic despite treatment with ACE inhibitors and beta-blockers 1, 3
Angiotensin receptor blockers (ARBs) are an alternative for patients who cannot tolerate ACE inhibitors, and may be considered in combination with ACE inhibitors in patients who remain symptomatic 3, 4
The European Society of Cardiology recommends sacubitril/valsartan as a replacement for ACE inhibitors in patients who remain symptomatic despite optimal treatment 3, 8
Cardiac glycosides (digoxin) are indicated for patients with atrial fibrillation and heart failure, and for patients in sinus rhythm who remain symptomatic despite ACE inhibitors and diuretics 5

Potassium-sparing diuretics should only be used if hypokalemia persists after initiation of ACE inhibitors and diuretics, starting with low doses and monitoring potassium and creatinine levels closely 1
Combination therapy should follow a logical sequence, starting with ACE inhibitors and diuretics, adding beta-blockers once patient is stabilized, and adding MRAs for patients who remain symptomatic 2, 3, 6

Avoid initiating potassium-sparing diuretics during initiation of ACE inhibitor therapy, and avoid NSAIDs in patients on ACE inhibitors as they may worsen renal function 2
Diltiazem and verapamil are not recommended in patients with reduced ejection fraction heart failure as they increase risk of worsening 3
Careful monitoring of renal function and electrolytes is essential when using ACE inhibitors, ARBs, and MRAs 2