What is the typical sequence of initiating therapies in chronic heart failure?

• A. ACE inhibitors or ARBs first, then beta-blocker, then spironolactone
• B. Beta-blocker first, then ACE inhibitors
• C. Spironolactone first, then ACE inhibitors
• D. Diuretics only; no further therapies

Answer: (A)

In chronic heart failure, therapies that improve survival are started in a careful, stepwise way to maximize benefit and tolerate each medication. Begin with an ACE inhibitor or an ARB because blocking the RAAS reduces mortality and remodeling and helps the heart work more efficiently. Once the patient tolerates that regimen and is hemodynamically stable, add a beta-blocker to blunt the harmful effects of chronic sympathetic activation, which further lowers mortality and slows disease progression. After both of these are established, and if the patient remains eligible (stable kidney function and potassium), introduce an aldosterone antagonist such as spironolactone to provide additional survival benefit and further remodeling improvement, with ongoing monitoring of potassium and renal function. Diuretics are used for symptom relief of congestion but do not confer the same long-term survival benefits, so they are not counted in the primary sequence of disease-modifying therapy.