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Heart Failure: Pharmacotherapy
D = Diuretics
I = Inotropes
V = Vasodilators
Green solid line = normal heart function
Red solid line = severe HF heart function
Most treatment below applies to CHRONIC systolic HFrEF, but it is also used in HFpEF
The ABCDD Acronym
A: ACEI/ARB/ARNI
B: Beta Blockers
C: Stage C Heart Failure
D: Digoxin
D: Diuretics
1. A: ACEI/ARB/ARNI
ACEI and ARB inhibits the cleavage of angiotensin I into angiotensin II (a
vasoconstrictor), which makes ACEI and ARB vasodilators, they promote cardiac
remodelling in heart failure
ARB should be used if ACEI is not tolerated, and ARNI should be used if both ACEI
and ARB are maximised but not responding well
ARNI i.e. Entresto (Sacubitril/Valsartan) consists of a ARB and a neprilysin inhibitor
that inhibits neprilysin, hence raising BNP and ANP levels to maintain cardiac
function
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Slow titration from initial dose to target dose is needed as increasing the dose too
quickly impairs the renal function
Double the dose of ACEI or ARB every 3 days until the target dose or not tolerated
(Serum Creatinine increase by >30%)
2. B: Beta Blockers
Only 3 are licensed for heart failure: Metoprolol, Bisoprolol, Carvedilol
Do not use BB in acute decompensated heart failure as it can worsen that by
inducing adrenergic stress (negative inotrope)
Titrate the dose very slowly to the target dose to avoid worsening heart failure (and
overcoming the adrenergic stress), doubling the dose every 2 weeks
Do not stop BB abruptly as BB causes a gradual increase in beta-receptors in the
heart and stopping a high dose abruptly can increase the risk of ischaemia and
myocardial infarction
3. C: Stage C Heart Failure
4 stages of heart failure
Stage 1: At high risk of HF but without structural heart disease or symptoms
of HF
Stage 2: Structural heart disease or symptoms of HF
Stage 3: Structural heart disease with current or prior symptoms of HF
Stage 4: Refractory HF
The NYHA classification of heart failure
Class I: Patients with cardiac disease but without resulting limitations of
physical activity. Ordinary physical activity does not cause undue fatigue,
palpitation, dyspnea, or anginal pain.
Class II: Patients with cardiac disease resulting in slight limitation of physical
activity. They are comfortable at rest. Ordinary physical activity results in
fatigue, palpitation, dyspnea, or anginal pain.
Class III: Patients with cardiac disease resulting in marked limitation of
physical activity. They are comfortable at rest. Less than ordinary physical
activity causes fatigue, palpitation, dyspnea, or anginal pain.
Class IV: Patients with cardiac disease resulting in inability to carry on any
physical activity without discomfort. Symptoms of cardiac insufficiency or
of the anginal syndrome may be present even at rest. If any physical
activity is undertaken, discomfort is increased.
Stage C HF should already have ACEI and BB and titrated up to target doses
If stage C HF is presented with NYHA Class II-IV, add aldosterone antagonist
(spironolactone - cheaper but causes gynaecomastia, eplerenone)
Points of starting an aldosterone antagonist:
K < 5mmol/L
eGFR > 30
Side effect of diuresis (potassium-sparing diuretic isn't the function we want in
heart failure)
4. D: Digoxin
Impact quality of life only, does not affect outcome
Reduces hospitalisations in HF patients
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5. D: Diuretics
Impact quality of life only, does not affect outcome
Important in managing fluid overload, reduces hospitalisations and decompensation
in HF patients
Furosemide: Do not give it 6 hours before sleep to avoid awakening
Hydralazine and isosorbide dinitrate
Use only when ACEI and BB are maximised
Ivabradine
affects HCN channels of the SA node, slowing firing of the SA
Use only when ACEI and BB are maximised, and resting heart rate > 70 bpm
Drug
Start Dose
Target Dose
ACE Inhibitor
Captopril
6.25 - 12.5 mg TID
25 - 50 mg TID
Enalapril
1.25 - 2.5 mg BID
10 mg BID
Ramapril
1.25 - 2.5 mg BID
5 mg BID
Lisinopril
2.5 - 5 mg Daily
20 - 35 mg Daily
Beta-Blocker
Carvedilol
3.125 mg BID
25 mg BID
Bisoprolol
1.25 mg Daily
10 mg Daily
Metoprolol CR/XL
12.5 - 25 mg Daily
200 mg Daily
ARB
Candesartan
4 mg Daily
32 mg Daily
Valsartan
40 mg BID
160 mg BID
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Aldosterone Antagonist
Spironolactone
12.5 mg Daily
50 mg Daily
Eplerenone
25 mg Daily
50 mg Daily
Vasodilator
Isosorbide Dinitrate
20 mg TID
40 mg TID
Hydralazine
37.5 mg TID
75 mg TID

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Heart Failure: Pharmacotherapy D = Diuretics I = Inotropes V = Vasodilators Green solid line = normal heart function Red solid line = severe HF heart function Most treatment below applies to CHRONIC systolic HFrEF, but it is also used in HFpEF The ABCDD Acronym A: ACEI/ARB/ARNI B: Beta Blockers C: Stage C Heart Failure D: Digoxin D: Diuretics 1. A: ACEI/ARB/ARNI ● ● ● ACEI and ARB inhibits the cleavage of angiotensin I into angiotensin II (a vasoconstrictor), which makes ACEI and ARB vasodilators, they promote cardiac remodelling in heart failure ARB should be used if ACEI is not tolerated, and ARNI should be used if both ACEI and ARB are maximised but not responding well ARNI i.e. Entresto (Sacubitril/Valsartan) consists of a ARB and a neprilysin inhibitor that inhibits neprilysin, hence raising BNP and ANP levels to maintain cardiac function ● ● Slow titration from initial dose to target dose is needed as increasing the dose too quickly impairs the renal function Double the dose of ACEI or ARB every 3 days until the target dose or not tolerated (Serum Creatinine increase by >30%) 2. B: Beta Blockers ● Only 3 are licensed for heart failure: Metoprolol, Bisoprolol, Carvedilol ● Do not use BB in acute decompensated heart failure as it can worsen that by inducing adrenergic stress (negative inotrope) ● Titrate the dose very slowly to the target dose to avoid worsening heart failure (and overcoming the adrenergic stress), doubling the dose every 2 weeks ● Do not stop BB abruptly as BB causes a gradual increase in beta-receptors in the heart and stopping a high dose abruptly can increase the risk of ischaemia and myocardial infarction 3. C: Stage C Heart Failure ● 4 stages of heart failure ○ Stage 1: At high risk of HF but without structural heart disease or symptoms of HF ○ Stage 2: Structural heart disease or symptoms of HF ○ Stage 3: Structural heart disease with current or prior symptoms of HF ○ Stage 4: Refractory HF ● The NYHA classification of heart failure ○ Class I: Patients with cardiac disease but without resulting limitations of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain. ○ Class II: Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain. ○ Class III: Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain. ○ Class IV: Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased. ● Stage C HF should already have ACEI and BB and titrated up to target doses ● If stage C HF is presented with NYHA Class II-IV, add aldosterone antagonist (spironolactone - cheaper but causes gynaecomastia, eplerenone) ● Points of starting an aldosterone antagonist: ○ K < 5mmol/L ○ eGFR > 30 ○ Side effect of diuresis (potassium-sparing diuretic isn't the function we want in heart failure) 4. D: Digoxin ● Impact quality of life only, does not affect outcome ● Reduces hospitalisations in HF patients 5. D: Diuretics ● Impact quality of life only, does not affect outcome ● Important in managing fluid overload, reduces hospitalisations and decompensation in HF patients ● Furosemide: Do not give it 6 hours before sleep to avoid awakening Hydralazine and isosorbide dinitrate ● Use only when ACEI and BB are maximised Ivabradine ● affects HCN channels of the SA node, slowing firing of the SA ● Use only when ACEI and BB are maximised, and resting heart rate > 70 bpm Drug Start Dose Target Dose ACE Inhibitor Captopril 6.25 - 12.5 mg TID 25 - 50 mg TID Enalapril 1.25 - 2.5 mg BID 10 mg BID Ramapril 1.25 - 2.5 mg BID 5 mg BID Lisinopril 2.5 - 5 mg Daily 20 - 35 mg Daily Beta-Blocker Carvedilol 3.125 mg BID 25 mg BID Bisoprolol 1.25 mg Daily 10 mg Daily Metoprolol CR/XL 12.5 - 25 mg Daily 200 mg Daily ARB Candesartan 4 mg Daily 32 mg Daily Valsartan 40 mg BID 160 mg BID Aldosterone Antagonist Spironolactone 12.5 mg Daily 50 mg Daily Eplerenone 25 mg Daily 50 mg Daily Vasodilator Isosorbide Dinitrate 20 mg TID 40 mg TID Hydralazine 37.5 mg TID 75 mg TID Name: Description: ...
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