Treatment of Heart Failure

Manegment of Heart failure
The treatment of heart failure has changed considerably over the past decade, primarily because we
now understand the importance of neurohormonal activation in the progression of this disease. In this
section we will learn about the treatment of heart failure; however, the focus will be on the ever-
expanding armamentarium the pharmacologic agents used to treat this disease.
**** [Note: Several major societies and organizations have published guidelines for the treatment of
HF. With few exceptions, these societies make similar recommendations regarding the treatment of
HFrEF .The material discussed in this section is based on the ACC/AHA Practice Guidelines 2017 and NICE
guideline [NG106] Published date: September 2018 ]
Goals of therapy - The goals of therapy of heart failure with reduced ejection fraction (HFrEF,
also known as systolic HF) are to :
- reduce morbidity (ie, reducing symptoms, improving health-related quality of life and functional
status, decreasing the rate of hospitalization)
- and to reduce mortality .
Approach to management — Management of heart failure with reduced ejection fraction

(HFrEF) includes management of contributing factors and associated conditions, lifestyle
modification, pharmacologic therapy, device therapy if indicated, cardiac rehabilitation, and
preventive care.
management of contributing and associated conditions include hypertension, ischemic heart

disease, valvular heart disease, diabetes, thyroid dysfunction, and infection.
Recommended lifestyle modifications for patients with HFrEF include smoking cessation,
restriction of alcohol consumption, salt restriction, weight reduction in obese patients, as well as
daily weight monitoring to detect fluid accumulation before it becomes symptomatic.
- The 2013 ACC/AHA HF guidelines suggest some degree (eg, <3 g/day) of sodium restriction
in patients with symptomatic HF. The 2016 ESC HF guidelines suggest avoiding excessive salt
intake (>6 g/day)
Pharmacologic therapy -
The goals of pharmacologic therapy of HFrEF are to improve symptoms (including risk of
hospitalization), slow or reverse deterioration in myocardial function, and reduce mortality .
* drugs that improve symptoms : diuretics, beta blockers, ACE inhibitors, ARBs,
ARNI, hydralazine plus nitrate, digoxin, and mineralocorticoid receptor antagonists MRAs.
* drugs that prolong survival : beta blockers, ACE inhibitors, ARNI, hydralazine plus nitrate, and
MRAs
the following sequence of pharmacologic therapy for patients with HFrEF (left ventricular
ejection fraction [LVEF] ≤40 percent), with allowance for variations depending upon clinical
response and presence of contraindications. (based in ACC/AHA recommendations ):
Initial therapy:
Initial therapy for HFrEF includes combination therapy with a diuretic therapy (as required to
treat volume overload); an ACE inhibitor, ARNI, or ARB; and a beta blocker.
 Loop diuretics are introduced first in patients in volume overload. Diuresis to relieve
signs and symptoms of volume overload is pursued while adverse effects are monitored.
- The most commonly used loop diuretic for the treatment of HF is furosemide, but some
patients respond better to bumetanide or torsemide because of superior and more
predictable absorption .
* The usual starting dose in outpatients with HF is 20 to 40 mg of furosemide or its
equivalent; the maximum suggested total daily dose of furosemide is 400 mg
* The usual initial oral dose of torsemide is 5 to 10 mg with maximum individual dose of
100 mg (maximum daily dose of 200 mg)
* The usual initial oral dose of bumetanide is 0.5 to 1.0 mg with maximum individual
dose of 5 mg (maximum daily dose of 10 mg)
 ACE inhibitor, ARNI, or ARB
The choice among these agents is based upon considerations of strength of evidence
for efficacy in improving outcomes (strongest for ARNI, intermediate for ACE inhibitor,
and weakest for ARB), meeting criteria for use and risk of side effects (higher risk of
hypotension with ARNI),
- In patients with a history of angioedema should not take an ACE inhibitor or ARNI, and
an ARB is preferred.
- Patients with an ACE inhibitor-related cough can be switched to an ARNI or ARB.
- ARNI and ARB intolerance can be presumed in patients who develop hyperkalemia or
renal insufficiency on ACE inhibitor therapy.
*ACE inhibitor dosing :

* When an ACE inhibitor is selected, low initial doses (eg, 2.5 to 5 mg of lisinopril once
daily, 2.5 mg of enalapril twice daily)
* If initial therapy is tolerated, the dose is then gradually increased at one- to two-week
intervals to, if tolerated, a target dose of 20 mg twice daily of enalapril or up to
40 mg/day of lisinopril
*ARBs dosing :
* candesartan (starting at 4 to 8 mg daily, titrated to a target dose of 32 mg daily)
or valsartan(starting at 20 to 40 mg twice daily, titrated to a target dose of 160 mg twice
daily)
 Beta blocker :
- Therapy should be begun at very low doses and the dose doubled at intervals of two
weeks or more until the target dose is reached or symptoms become limiting . Initial and
target doses are:
* For carvedilol immediate release, 3.125 mg twice daily initially and 25 to 50 mg twice

daily ultimately (the higher dose can be used in subjects over 85 kg)
* For extended-release metoprolol (metoprolol succinate), 12.5 mg daily in patients with

New York Heart Association (NYHA) class III or IV symptoms or 25 mg daily in patients
with NYHA II symptoms, and ultimately 200 mg/day.
* For bisoprolol, 1.25 mg once daily initially and 5 to 10 mg once daily ultimately.
Additional therapy:
The following drugs are indicated in selected patients identified by their response to
initial therapy described above.
 Mineralocorticoid receptor antagonist :
We recommend mineralocorticoid receptor antagonist ( spironolactone or eplerenone )
therapy (in addition to angiotensin converting enzyme [ACE] inhibitor or angiotensin II
receptor blocker [ARB] or angiotensin receptor-neprilysin inhibitor and beta blocker
therapy) in patients who have New York Heart Association (NYHA) functional class II HF
and an left ventricular ejection fraction (LVEF) ≤30 percent, or NYHA functional class III
to IV HF and an LVEF <35 percent,
* starting with spironolactone 12.5 to 25 mg once daily and after four weeks doubling

the dose to 25 mg once or twice daily if serum potassium is ≤5.0 meq/L
* A switch to eplerenone (25 mg once daily and after four weeks increasing to 50 mg
once daily if serum potassium is <5.0 meq/L) is recommended if endocrine side effects
occur with spironolactone.
 Ivabradine :
For patients with chronic stable HF with LVEF ≤35 percent, in sinus rhythm with a resting
heart rate ≥70 beats per minute, and who either are on a maximum tolerated dose of a
beta blocker or have a contraindication to beta blocker use,
 Hydralazine plus nitrate :
For patients with HFrEF who can take neither an ACE inhibitor nor an ARB due to drug
intolerance, hypotension, or renal insufficiency
* Starting doses of hydralazine 25 mg three times daily and isosorbide dinitrate 20 mg

three times daily are recommended. Uptitration of dose should be considered every two
to four weeks. The dose should not be increased if symptomatic hypotension develops.
The target dose is hydralazine 75 mg three times daily and isosorbide dinitrate (40 mg
three times daily).
 Digoxin :
reserve use of digoxin for patients with HFrEF who continue to have NYHA functional
class III and IV symptoms despite optimal therapy;
* dose : Digoxin dose is individualized based upon renal function, ideal body weight, and
concomitant medications that may affect digoxin levels
- 0.125 mg per day for individuals with a creatinine clearance ≥30 mL/min.
- 0.0625 per day (which can be given as 0.125 mg every other day) for individuals with a
creatinine clearance <30 mL/min.
duration of therapy : Pharmacologic therapy for treatment of HFrEF is

generally continued indefinitely, as tolerated, although limited data on the optimum
duration of therapy are available.
summary of AHA recommendations :
Summary : drug dosing
Source : AAFP : American Academy of Family Physician

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Manegment of Heart failure

Approach to management — Management of heart failure with reduced ejection fraction

management of contributing and associated conditions include hypertension, ischemic heart

*ACE inhibitor dosing :

* For carvedilol immediate release, 3.125 mg twice daily initially and 25 to 50 mg twice

* For extended-release metoprolol (metoprolol succinate), 12.5 mg daily in patients with

* starting with spironolactone 12.5 to 25 mg once daily and after four weeks doubling

 Hydralazine plus nitrate :

* Starting doses of hydralazine 25 mg three times daily and isosorbide dinitrate 20 mg

duration of therapy : Pharmacologic therapy for treatment of HFrEF is

Source : AAFP : American Academy of Family Physician

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