How should I initiate and titrate pharmacological treatment for a patient with newly diagnosed chronic heart failure?

Start pharmacological treatment in patients with newly diagnosed chronic heart failure by offering an angiotensin-converting enzyme (ACE) inhibitor and a beta-blocker, using clinical judgment to decide which to start first, especially if the patient has diabetes or signs of fluid overload ¹.

Begin ACE inhibitor therapy at a low dose and titrate upwards at short intervals (for example, every 2 weeks) until the target or maximum tolerated dose is reached, with regular monitoring of serum sodium, potassium, renal function, and blood pressure ¹.

Introduce beta-blockers in a 'start low, go slow' manner, assessing heart rate, clinical status, and blood pressure after each titration ¹.

Once the target or maximum tolerated dose of these medications is achieved, monitor treatment monthly for 3 months, then at least every 6 months, and during any acute illness ¹.

If symptoms persist despite optimal doses, consider adding a mineralocorticoid receptor antagonist (MRA) and continue titration and monitoring as above ¹.

In cases where ACE inhibitors are not tolerated, consider angiotensin-II receptor antagonists (ARBs) with similar titration and monitoring protocols ¹.