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Treatments recommended in
potentially all patients with systolic heart
Angiotensin-converting enzyme inhibitors
--ACE inhibitors have a modest effect on LV remodelling whereas
beta-blockers often lead to a substantial improvement in EF.
--ACEI[Cooperative North Scandinavian Enalapril Survival Study
(CONSENSUS) and Studies of Left Ventricular Dysfunction (SOLVD)-
--SE worsening of renal function, hyperkalaemia, symptomatic
hypotension, cough, and, rarely,
angioedema. An ACE inhibitor should only be used in patients with
adequate renal function (creatinine ≤2.5 mg/dL or eGFR ≥30
mL/min/1.73 m2) and a normal serum potassium level
-patients should be rechallenged, because many will not redevelop
a cough, suggesting the initial development of cough was coincidental
and may have been related to heart failure
--BB [Cardiac Insufficiency Bisoprolol Study II (CIBIS II),
Carvedilol Prospective Randomized Cumulative Survival
(COPERNICUS), and Metoprolol CR/XL Randomised Intervention
Trial in Congestive Heart Failure (MERIT-HF), Study of Effects of
Nebivolol Intervention on Outcomes and Rehospitalization in Seniors
With Heart Failure (SENIORS)]
--Should usually be initiated in stable patients, and used only with
caution in recently decompensated patients (and only initiated in
hospital in these patients). Recently decompensated patients were,
however, safely initiated on betablocker treatment in COPERNICUS
--Temporary discontinuation is advised in shocked or severely
hypoperfused patients. Re-institution of treatment should be
attempted before discharge.
- β-Blockers should be initiated at low doses, uptitrated gradually .
achieve target doses in 8 to 12 weeks from initiation of therapy
- β-Blocker therapy should only be initiated when patients are euvolemic and hemodynamically
stable, are usually on a good maintenance dose of diuretics (if indicated), and receiving
ACE inhibitors or ARBs.
- If patient symptoms worsen during initiation or dose titration, the dose of diuretics or other
concomitant vasoactive medications should be adjusted, and titration to target dose should
be continued after the patient’s symptoms return to baseline.
- If uptitration continues to be difficult, the titration interval can be prolonged, the target dose
may have to be reduced, or the patient should be referred to a heart failure specialist.
- If an acute exacerbation of chronic heart failure occurs, therapy should be maintained if
possible; the dose can be reduced if necessary, but abrupt discontinuation should be avoided.
If the dose is reduced (or discontinued), the β-blocker (and prior dose) should be gradually
reinstated before discharge, if possible.
Mineralocoricoid Receptor Antagonist
--MRA [Randomized Aldactone Evaluation Study (RALES)
trial, Eplerenone in Mild Patients Hospitalization and Survival
Study in Heart Failure (EMPHASIS-HF), Eplerenone Post-
Acute Myocardial Infarction Heart Failure Efficacy and Survival
--Spironolactone and eplerenone can cause hyperkalaemia and
worsening renal function should only be used in
patients with adequate renal function and a normal serum
potassium concentration; if either is used, serial monitoring of
serum electrolytes and renal function is mandatory.
--Spironolactone can also cause breast discomfort and
enlargement in men (10% compared with 1% on placebo, in
RALES); this side effect is infrequent with eplerenone.
-Hydralazine: start at 37.5 mg three times a day and increase to a goal of 75
mg three times a day.
-Isosorbide dinitrate: start at 20 mg three times a day and increase to a goal of
40 mg three
times a day.
=Those who cannot take an ACE inhibitor or ARB because of renal
insufficiency or hyperkalemia
= Those who are hypertensive and/or symptomatic despite taking ACE
inhibitor, ARB, and
= The combination of hydralazine and nitrates is recommended to improve
patients self-described as African Americans with moderate-severe symptoms
medical therapy with ACE inhibitors, β-blockers, and diuretics.
--ARBs are no longer the first choice recommendation in
patients with HF and an EF ≤40% who remain
symptomatic despite optimal treatment with an ACE
inhibitor and beta-blocker. This is because in EMPHASIS-
HF, eplerenone led to a larger reduction in morbidity–
mortality than seen in the ARB ‘add-on’ trials discussed
below, and because in both the Randomized Aldactone
Evaluation Study (RALES) and EMPHASIS-HF, MRA
treatment reduced all-cause mortality, whereas ARB ‘add-
on’ treatment did not.
--[Valsartan Heart Failure Trial (Val-HeFT) and CHARM-
Added]reduced the risk of HF hospitalization (RRR 24%
in Val-HeFT and 17% in CHARM-Added) but not all-cause
--Ivabradine is a drug that inhibits the If channel in the sinus node. Its only
known pharmacological effect is to slow the heart rate in patients in sinus
rhythm (it does not slow the ventricular rate in AF).
-- The Systolic Heart failure treatment with the If inhibitor ivabradine Trial
(SHIFT) enrolled 6588 patients in NYHA functional class II–IV, sinus rhythm
with a rate of ≥70 b.p.m., and an EF ≤35% randomized to ivabradine (up-
titrated to a maximal dosage of 7.5 mg twice daily) or placebo, added to a
diuretic (in 84%), digoxin (22%), an ACE inhibitor (79%), an ARB (14%), a
beta-blocker (90%), and an MRA (60%). Only 26% of patients were, however,
on full-dose beta-blocker the reduction in cardiovascular death (or all-cause
death) was not significant, but the RRR in HF hospitalization was 26%
-- Safety evidence for ivabradine comes from the MorBidity-mortality
EvAlUaTion of the If inhibitor ivabradine in patients with coronary disease
and left ventricULar dysfunction (BEAUTIFUL) trial, an RCT in which 10 917
patients with coronary heart disease and an EF ,40% were assigned to
treatment with ivabradine 7.5 mg twice daily or placebo and followed for a
median of 19 months. Although ivabradine did not reduce the primary
outcome of cardiovascular death, myocardial infarction, or HF
hospitalization, it was well tolerated
-Inhibitors of the Na-K ATPase pump in the sarcolemic membrane of the myocyte and other cells.
This inhibition causes intracellular accumulation of Na, which makes the Na-Ca pump extrude less
Ca, causing Ca to accumulate inside the cell. Cardiac glycosides also enhance parasympathetic and
reduce sympathetic outputs to the heart, through carotid sinus baroreflex sensitization.
-Digoxin has a narrow safety margin (the difference in plasma drug concentrations between
therapeutic and toxic levels is small). Patients with digoxin toxicity may manifest nausea,
vomiting, anorexia, diarrhea, fatigue, generalized malaise, visual disturbances (green or yellow
halos around lights and objects), and arrhythmias. In the presence of hypokalemia, digoxin
toxicity may occur within the therapeutic level. Digoxin dose should be reduced in elderly
patients, in patients with renal insufficiency (glomerular filtration rate [GFR] less than 60 ml/
& Sinus bradycardia
& Sinus arrest
& First- and second-degree AV block
& AV junctional escape
& Paroxysmal atrial tachycardia with AV block
& Bidirectional ventricular tachycardia
& Premature ventricular beats
& Regularized atrial fibrillation or atrial fibrillation with slow ventricular response (common)
-Digoxin withdrawal is sufficient with only suggestive symptoms.
-Activated charcoal may enhance the gastrointestinal (GI) clearance of digoxin if given within 6
hours of ingestion. Drugs that increased plasma digoxin levels (Quinidine, verapamil, amiodarone,
propafenone, and quinine) should be discontinued (except amiodarone because of its long half-
-Correction of hypokalemia is vital (intravenous [IV] replacement through a large vein is preferred
with life-threatening arrhythmias).
-Symptomatic AV block may respond to atropine or to phenytoin (100 mg IV every 5 minutes up to
1000 mg until response or side effects); if no response, use Digibind. The use of temporary
transvenous pacing should be avoided.
-Patients with severe bradycardia should be given Digibind, even if they respond
-Lidocaine and phenytoin may be used to treat ventricular arrhythmias, but for
potentially life-threatening bradyarrhythmias or tachyarrhythmias, Digibind should be used.
-Dialysis has no role because of the high tissue binding of digoxin.
14-18mg/kg IV direct
5mg/kg/day (in divided doses every 8 hours)
Treatments not recommended
--Statins: Two recent trials(CORONA and GISSI-HF) studied
statin treatment specifically in patients with chronic HF and did
not demonstrate convincing evidence of benefit (although there
was little evidence of harm).Despite the evidence in other areas
of cardiovascular medicine, the evidence does not therefore
support the initiation of statins in most patients with chronic
-- Direct renin inhibitor (aliskiren) is not presently
recommended as an alternative to an ACE inhibitor or ARB.
-- Other than in patients with AF (both HF-REF and HF-PEF),
there is no evidence that an oral anticoagulant reduces
mortality–morbidity compared with placebo or aspirin.
-LV thrombus INR 2.0–3.0 for at least 3 months
and up to 1 year
--No mortality or morbidity effect studied,,, symptomatic.
-- Loop diuretics produce a more intense and shorter diuresis than
thiazides, which cause a more gentle and prolonged diuresis.
Thiazides may be less effective in patients with reduced kidney
-- Do not use thiazides if estimated glomerular filtration rate <30
mL/min, except when prescribed synergistically with loop diuretics.
-- Self-adjust of diuretic dose, based on monitoring of symptoms/signs
of congestion and daily weight measurements.
-- † If a potassium-losing diuretic is used with the combination of an
ACE inhibitor and an MRA (or ARB), potassium replacement is
usually not required.
† Serious hyperkalaemia may occur if potassium-sparing diuretics
or supplements are taken in addition to the combination of an
ACE inhibitor (or ARB) and MRA.
from 2009 Focused Update states that for hospitalized
heart failure patients, if diuresis is
inadequate to relieve congestion, higher doses of loop
diuretics should be used, addition of second
diuretic should be made or continuous infusion of a
loop diuretic should be considered.
Heart failure with ‘preserved’ ejection fraction
(diastolic heart failure)
-- Diuretics are used to control sodium and water retention
and relieve breathlessness and oedema
-- Adequate treatment of hypertension and myocardial
-- The drugs that should be avoided in HF-REF should also
be avoided in HF-PEF, with the exception of CCBs.
-- (CHARM)-Preserved Trial, Perindopril for Elderly
People with Chronic Heart failure trial (PEP-CHF),
Irbesartan in heart failure with preserved systolic function
trial (I-Preserve) no reduction in the primary composite
endpoint of death or HF hospitalization
=Control of systolic and diastolic hypertension as per published hypertension guidelines
= Control of ventricular rate in atrial fibrillation
= Diuretics to control pulmonary congestion and peripheral edema
= Consider revascularization in patients with significant coronary artery disease and symptoms
and/or demonstrable ischemia, where ischemia may be regarded as a contributor to abnormal
= Restoration and maintenance of sinus rhythm in certain patients with atrial fibrillation may
be useful to control symptoms
= β-blockers can be considered for HFpEF with:
○ Prior myocardial infarction
○ Atrial fibrillation
= ACE inhibitors or ARBs can be considered for HFpEF with:
○ Atherosclerotic vascular disease
= Calcium channel blockers can be considered for HFpEF with:
○ Atrial fibrillation requiring control of ventricular rate in patients for whom blockers have
proven inadequate: consider diltiazem or verapamil
○ Symptom-limiting angina
○ Hypertension: consider amlodipine
= Digitalis may be considered for rate control in atrial fibrillation if not responsive to other
agents listed above.
Non-surgical device treatment of systolic heart
failure: I- ICD
-- The most common arrhythmia in HF.
-- Identification of correctable causes (e.g. hyperthyroidism,
electrolyte disorders, uncontrolled hypertension, mitral valve disease).
--Identification of potential precipitating factors (e.g. recent surgery,
chest infection or exacerbation of chronic pulmonary disease/asthma,
acute myocardial ischaemia, alcohol binge) as this may determine
whether a rhythm-control strategy is preferred to a rate-control
--Assessment for thromboembolism prophylaxis.
--Rhythm control is probably best reserved for patients with a
reversible secondary cause of AF (e.g. hyperthyroidism) or an obvious
precipitant (e.g. recent pneumonia) and in patients who cannot
tolerate AF after optimization of rate control and HF therapy.
--Amiodarone is the only antiarrhythmic that should be used in
patients with systolic HF.
--CHA2DS2-VASc vs HASBLED
Symptomatic bradycardia, atrioventricular block
--Before implanting a conventional pacemaker in a patient with
HF-REF, consider whether there is an indication for an ICD,
CRT-P, or CRT-D.
--Because right ventricular pacing may induce dyssynchrony and
worsen symptoms, CRT should be considered instead of conventional
pacing in patients with HF-REF.
--Physiological pacing to maintain an adequate chronotropic response
and maintain atrial–ventricular coordination with a DDD system is
preferable to VVI pacing in patients with both HF-REF and HF-PEF.
--Pacing solely in order to permit initiation or titration of betablocker
therapy in the absence of a conventional indication is not