Managing Air Hunger and Anxiety in Chronic Systolic Heart Failure

Introduction to Guideline-Directed Medical Therapy

The American College of Cardiology recommends optimizing guideline-directed medical therapy with quadruple therapy, which provides a 73% mortality reduction over 2 years, in patients with chronic systolic heart failure with reduced ejection fraction 1, 2

The European Society of Cardiology suggests determining if fluid overload is present by examining for peripheral edema, elevated jugular venous pressure, and rapid weight gain, with associated citations 2, 3
The American Heart Association recommends starting loop diuretics immediately for rapid symptom relief if fluid overload is present, and combining diuretics with ACE inhibitors or ARNI, with a strength of evidence based on 3

The American College of Cardiology recommends simultaneous initiation of all four medication classes (SGLT2 inhibitor, ARNI/ACE inhibitor, beta-blocker, and mineralocorticoid receptor antagonist) for the most rapid mortality benefit and symptom relief, with a high strength of evidence based on 2
The European Society of Cardiology suggests uptitrating every 1-2 weeks using a forced-titration strategy, with targets including ARNI 97/103mg twice daily, beta-blocker targets (e.g. carvedilol 25-50mg twice daily), and MRA target (spironolactone 25-50mg daily), with associated citations 1, 2, 4

The American Heart Association recommends not discontinuing or reducing medications for asymptomatic hypotension, as this can compromise long-term outcomes, with a strength of evidence based on 2
The European Society of Cardiology suggests accepting modest creatinine increases (up to 30% above baseline) and not stopping ACE inhibitor/ARNI unless renal function deteriorates substantially, with associated citations 1, 4

The American College of Cardiology recommends counseling patients and families that dyspnea and anxiety will improve with medication optimization, with a strength of evidence based on 3

The American Heart Association recommends avoiding NSAIDs, excessive diuresis before starting ACE inhibitors/ARNI, and potassium-sparing diuretics during ACE inhibitor/ARNI initiation, with associated citations 2, 3, 4

The European Society of Cardiology suggests achieving optimal therapy within 2 months, with early follow-up within 7-14 days after medication adjustments, and continuing uptitration every 1-2 weeks until target doses are achieved, with associated citations 1, 2

The American College of Cardiology recommends never discontinuing guideline-directed medical therapy even if ejection fraction improves, as discontinuation leads to clinical deterioration, with a high strength of evidence based on 2
The European Society of Cardiology suggests that only 1% of eligible patients receive target doses of all recommended drugs, representing a major treatment gap, with associated citations 2, 5