A practical guide for primary care on early detection, stage-based management, and multidisciplinary collaboration to prevent heart failure progression.

Published: October 16, 2025

Heart failure affects more than 6 million Americans, with Kentucky facing particularly high death rates of this complex cardiovascular syndrome. For primary care providers, understanding the full spectrum of heart failure — from at-risk patients to those requiring advanced therapies — is crucial for improving outcomes and quality of life. Chioma O. Obiokoye, M.D., heart failure cardiologist with Norton Heart & Vascular Institute Advanced Heart Failure & Recovery Program, outlines a guide of stages and evidence-based care strategies for primary care providers that present opportunities for intervention that can alter the disease trajectory and improve patient outcomes.

Understanding the heart failure continuum

Heart failure represents a clinical syndrome where the heart cannot adequately fill or squeeze, leading to symptoms or putting patients at risk for developing other organ damage. The condition progresses through four distinct stages, creating a one-way street from Stage A through Stage D.

• Stage A patients are at risk but asymptomatic, including those with obesity, hypertension, diabetes, hyperlipidemia, exposure to cardio-toxic medications, genetic variant for cardiomyopathy or familial cardiomyopathy.
• Stage B represents pre-heart failure, where patients have left ventricular ejection fraction less than 40%, structural heart disease like reduced ejection fraction, reduced strain, mitral regurgitation, aortic stenosis, left ventricular hypertrophy or elevated biomarkers but remain symptom-free.
• Stage C patients develop symptomatic heart failure with classic signs of congestion.
• Stage D represents advanced heart failure requiring specialized interventions.

Stage-specific management strategies

Stage A: Prevention is key

• Target blood pressure below 130/80 mmHg following American College of Cardiology guidelines.
• Optimize diabetes control; adding Sodium-glucose cotransporter 2 (SGLT2) inhibitors (dapagliflozin/empagliflozin) could be used to prevent hospitalizations in patients with type 2 diabetes mellitus and cardiovascular disease.
• Implement obesity management and physical activity programs.
• Consider angiotensin-converting enzyme (ACE) inhibitors and beta-blockers for high-risk patients.
• High cardiovascular risk patients would benefit from referral to a cardiovascular specialist.

Stage B: Structural changes without symptoms

Continue Stage A interventions while monitoring for symptom development.

To prevent or delay progression of heart failure, consider referring patients to the heart failure clinic for further evaluation and management.

 For patients with ejection fraction 30% or less who are more than 40 days post-myocardial infarction with greater than one-year life expectancy, consider cardiology referral for primary prevention implantable cardioverter-defibrillator (ICD) evaluation.

Statins should be added to prevent symptomatic heart failure and adverse cardiovascular events.

Stage C: Symptomatic management

The goal shifts to symptom control, decongestion and quality of life improvement. It is important to refer patient to the heart failure specialists to implement guideline-directed medical therapy (GDMT) with four pillars:

1. ACE inhibitors/angiotensin II receptor blockers (ARBs) or angiotensin receptor/neprilysin inhibitor (sacubitril/valsartan)
2. Beta-blockers
3. Mineralocorticoid receptor antagonists (spironolactone/eplerenone)
4. Sodium-glucose cotransporter 2 (SGLT2) inhibitors (dapagliflozin/empagliflozin)

Additional therapies

For patients with ejection fraction below 35% despite optimal medical therapy for three months, consider:

• ICD for primary prevention of sudden cardiac death
• Cardiac resynchronization therapy (CRT) for wide QRS with New York Heart Association Class II to Class III symptoms.
• Additional medications like ivabradine for heart rate above 70 beats per minute
• Digoxin and vericiguat for persistent symptoms.

Managing medication challenges

Hyperkalemia should not automatically lead to discontinuation of lifesaving medications like ACE inhibitors or spironolactone. Potassium binders can enable continuation of optimal heart failure therapy while managing electrolyte imbalances.

For African American patients or those unable to tolerate ACE inhibitors or ARBs, the combination of hydralazine and isosorbide dinitrate provides proven mortality benefit.

Heart failure with preserved ejection fraction

Patients with normal ejection fraction but heart failure symptoms present diagnostic challenges. Look for:

• Age over 60
• Atrial fibrillation
• Elevated filling pressures on echocardiogram
• Pulmonary hypertension
• Clinical heart failure signs and symptoms

Management focuses on blood pressure control, decongestion and addressing underlying conditions like atrial fibrillation and sleep apnea.

SGLT2 inhibitors, mineralocorticoid receptor antagonists, angiotensin receptor blockers (ARB)/ or angiotensin receptor/neprilysin inhibitor (sacubitril/valsartan) offer benefit of reducing heart failure hospitalizations. SGLT2 inhibitors also decreases cardiovascular mortality.

Medications to avoid

In patients with ejection fraction below 40%, avoid:

• Pioglitazone
• Verapamil and diltiazem
• Nonsteroidal anti-inflammatory drugs
• Saxagliptin and alogliptin

These medications can worsen heart failure outcomes and should be discontinued or avoided.

Stage D: Immediate referral for advanced care

A patient requires immediate Heart failure program referral when experiencing:

• Medication discontinuation due to intolerance.
• Hypotension and high heart rate
• End organ dysfunction.
• Defibrillator shocks
• Frequent hospitalizations or emergency room visits despite optimal heart failure therapy
• Ejection fraction below 35%
• Poor quality of life despite maximum medical therapy
• Needing intravenous inotrope medications
• Edema despite increasing dose of diuretics.

Advanced options include ventricular assist devices, heart transplantation or palliative care discussions.

The team approach

Successful heart failure management requires coordination between primary care, cardiology, pharmacy, nutrition and other specialists. Early initiation of heart failure GDMT in the outpatient setting or during hospitalization improves long-term adherence and outcomes.

Primary care providers play a crucial role in identifying at-risk patients, implementing preventive measures and optimizing medical therapy before referring for advanced interventions. By understanding the heart failure continuum and implementing evidence-based strategies at each stage, clinicians can significantly impact both the quantity and quality of life for their patients.

The key message remains clear: Heart failure progression is preventable through early recognition, appropriate medical therapy and coordinated, team-based care. Every stage offers opportunities for intervention that can alter the disease trajectory and improve patient outcomes.

Clinical pearls for early detection

• Watch for subtle presentations that may signal heart failure before classic symptoms emerge, including nausea and right upper quadrant pain. These can lead to unnecessary gastrointestinal workups when the underlying issue is cardiac.
• Look for “bendopnea” — shortness of breath when bending over. This indicates elevated filling pressures and should prompt cardiovascular evaluation.
• For outpatient diagnosis, N-terminal pro-B-type natriuretic peptide (BNP) levels above 125 picograms per milliliter or BNP above 35 picograms per milliliter support the diagnosis when combined with clinical context. However, obese patients may have falsely low BNP levels, requiring careful clinical correlation with symptoms and signs.
• Consider outlined factors for patients presenting with normal ejection fraction but still exhibiting heart failure symptoms