Chronic heart failure.

The clinical diagnosis of heart failure should be confirmed by echocardiogram to determine the underlying mechanism and to measure the left ventricular ejection fraction. Heart failure with reduced ejection fraction and heart failure with preserved ejection fraction have different treatments but are often indistinguishable clinically. Lifestyle modification and education on self-management are important strategies for all patients. Patients should monitor their symptoms and weight regularly. Heart failure with reduced ejection fraction should be managed with ACE inhibitors, heart failure specific beta blockers, and aldosterone antagonists. These drugs all reduce mortality. Angiotensin receptor antagonists should be used if the patient cannot tolerate ACE inhibitors. The combination of sacubitril and valsartan is indicated if patients remain symptomatic despite ACE inhibitors, beta blockers and aldosterone antagonists. Digoxin and diuretics may also have a role in treating persistent symptoms. In heart failure with preserved ejection fraction no drug has been proven to reduce mortality. Patients should be treated cautiously with diuretics and have aggressive management of risk factors, particularly hypertension.