management of mild to moderate heart failure

Last edited 10/2018 and last reviewed 05/2023

The management of mild to moderate congestive failure consists of:

• lifestyle and risk factor management
• diuretics, for symptom control
• drug treatment recommended by NICE for left ventricular dysfunction is summarised below (1):

  First line treatment:

• offer both angiotensin-converting enzyme (ACE) inhibitors and beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction. Use clinical judgement when deciding which drug to start first
  • ACE inhibitor
    • NICE recommends that all patients with left ventricular dysfunction should be taking an ACE inhibitor (1,2)
    • specialist referral is required for patients requiring high doses of diuretics, or exhibiting worsening renal function at any stage - note that some degree of detioration of renal function after initiating ACE inhibitors is inevitable, but if this is only small only monitoring is necessary
  • beta blockers
    • introduce beta-blockers in a 'start low, go slow' manner. Assess heart rate and clinical status after each titration. Measure blood pressure before and after each dose increment of a beta-blocker
      • beta-blocker therapy should be started at a very low dose (e.g. carvedilol 3.125mg once daily) and titrated slowly over a period of weeks or months. The beta-blocker should be up-titrated at fortnightly intervals (or longer in more sensitive patients) to a target dose of carvedilol 25-50mg bd or bisoprolol 10mg od (2,3)
  • offer beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction, including:
    • older adults and
    • patients with:
      • peripheral vascular disease
      • erectile dysfunction
      • diabetes mellitus
      • interstitial pulmonary disease and
      • chronic obstructive pulmonary disease (COPD) without reversibility
  • mineralocorticoid receptor antagonists (MRA) (aldosterone receptor antagonists) e.g. spironolactone
    • an MRA should be offered, in addition to an ACE inhibitor (or ARB) and beta-blocker, to people who have heart failure with reduced ejection fraction if they continue to have symptoms of heart failure
    • measure serum sodium and potassium, and assess renal function, before and after starting an MRA and after each dose increment
    • measure blood pressure before and after after each dose increment of an MRA
    • once the target, or maximum tolerated, dose of an MRA is reached, monitor treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell

Alternative first line treatment

• angiotensin II receptor antagonists (ARB’s) - can be used as an alternative in patients who are intolerable to ACE inhibitors

Second line treatment

• specialist advice should be obtained before commencing second line therapy in patients with HF due left ventricular systolic dysfunction
• specialist treatment options include (must seek specialist advice):
  • ivabradine
    • an option for treating chronic heart failure for people:
      • with New York Heart Association (NYHA) class II to IV stable chronic heart failure with systolic dysfunction and
      • who are in sinus rhythm with a heart rate of 75 beats per minute (bpm) or more and
      • who are given ivabradine in combination with standard therapy including beta-blocker therapy, angiotensin-converting enzyme (ACE) inhibitors and aldosterone antagonists, or when beta-blocker therapy is contraindicated or not tolerated and
      • with a left ventricular ejection fraction of 35% or less
  • sacubitril valsartan
    • an option for treating symptomatic chronic heart failure with reduced ejection fraction, only in people:
      • with New York Heart Association (NYHA) class II to IV symptoms and
      • with a left ventricular ejection fraction of 35% or less and
      • who are already taking a stable dose of angiotensin-converting enzyme (ACE) inhibitors or ARBs
  • hydralazine in combination with nitrate
    • seek specialist advice and consider offering hydralazine in combination with nitrate (especially if the person is of African or Caribbean family origin and has moderate to severe heart failure [NYHA class III/IV] with reduced ejection fraction)
  • digoxin
    • recommended for worsening or severe heart failure with reduced ejection fraction despite first-line treatment for heart failure

Notes:

• aldosterone antagonists in left ventricular dysfunction
  • in patients with heart failure due to left ventricular systolic dysfunction who are taking aldosterone antagonists, closely monitor potassium and creatinine levels, and eGFR. Seek specialist advice if the patient develops hyperkalaemia or renal function deteriorates
  • for patients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, treatment with an aldosterone antagonist licensed for post-MI treatment should be initiated within 3-14 days of the MI, preferably after ACE inhibitor therapy
  • patients who have recently had an acute MI and have clinical heart failure and left ventricular systolic dysfunction, but who are already being treated with an aldosterone antagonist for a concomitant condition (for example, chronic heart failure), should continue with the aldosterone antagonist or an alternative, licensed for early post-MI treatment.
• ARBs in left ventricular dysfunction
  • consider an ARB licensed for heart failure as an alternative to an ACE inhibitor for patients with heart failure due to left ventricular systolic dysfunction who have intolerable side effects with ACE inhibitors
  • monitor serum urea, electrolytes, creatinine and eGFR for signs of renal impairment or hyperkalaemia in patients with heart failure who are taking an ARB
• digoxin in left ventricular dysfunction
  • digoxin is recommended for:
    • worsening or severe heart failure due to left ventricular systolic dysfunction despite first- and second-line treatment for heart failure

Reference:

1. NICE (September 2018).Chronic heart failure in adults: diagnosis and management
2. NICE (August 2010). Chronic heart failure
3. Geriatric Medicine (2005); 35 (1):37-42