Congestive heart failure chronic pharmacotherapy

Congestive Heart Failure Microchapters
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Pathophysiology Systolic Dysfunction Diastolic Dysfunction HFpEF HFrEF
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Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF Diuretics ACE Inhibitors Angiotensin receptor blockers Aldosterone Antagonists Beta Blockers Ca Channel Blockers Nitrates Hydralazine Positive Inotropics Anticoagulants Angiotensin Receptor-Neprilysin Inhibitor Antiarrhythmic Drugs Nutritional Supplements Hormonal Therapies Drugs to Avoid Drug Interactions Treatment of underlying causes Associated conditions
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Surgical Therapy: Biventricular Pacing or Cardiac Resynchronization Therapy (CRT) Implantation of Intracardiac Defibrillator Ultrafiltration Cardiac Surgery Left Ventricular Assist Devices (LVADs) Cardiac Transplantation
ACC/AHA Guideline Recommendations Initial and Serial Evaluation of the HF Patient Hospitalized Patient Patients With a Prior MI Sudden Cardiac Death Prevention Surgical/Percutaneous/Transcather Interventional Treatments of HF Patients at high risk for developing heart failure (Stage A) Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B) Patients with current or prior symptoms of heart failure (Stage C) Patients with refractory end-stage heart failure (Stage D) Coordinating Care for Patients With Chronic HF Quality Metrics/Performance Measures
Implementation of Practice Guidelines
Congestive heart failure end-of-life considerations
Specific Groups: Special Populations Patients who have concomitant disorders Obstructive Sleep Apnea in the Patient with CHF NSTEMI with Heart Failure and Cardiogenic Shock
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Assistant editor-in-chief Rim Halaby

Overview

There are several goals in the chronic management of systolic heart failure. The management of diastolic heart failure is discussed elsewhere. The first goal is to treat the patient's symptoms of heart failure and to improve the patient's exercise tolerance and quality of life. The use of diuretics and regular assessment of the patient's weight helps in avoiding excess body fluids that are associated with dyspnea and orthopnea. Another goal of the chronic treatment of heart failure is to decrease the rate of hospitalization and mortality. To cheat the second goal, patients with chronic heart failure should be administered an ACE inhibitor (or ARB if they are ACE intolerant) and a beta blocker. If the patient remains symptomatic, additional therapy may be advised.

Chronic Pharmacotherapy

Treatment Goals

Improvement of symptoms:

• ACE inhibitors
• ARBs
• Beta blockers
• Diuretics
• Digoxin

Decreased Mortality:

• ACE inhibitors
• ARBs
• Beta blockers
• Diuretics (in meta-analyses)
• Nitrates and hydralazine
• Spironolactone

A General Strategy in the Chronic Treatment of Heart Fialure

• First, begin by rapidly improving the symptoms of heart failure (within hours to days) by the use of diuretics. Diuretics reduce excess volume that accumulates with heart failure and decrease pulmonary edema that causes symptoms of dyspnea and orthopnea. Lasix 20 to 40 mg PO daily is a conventional starting dose, but in some patients, torsemide may have better and more predictable absorption. Once a day dosing of a givne diuretic is preferred to twice a day dosing at a lower dose.

• Simultaneous with number 1

• Treat the underlying cause of heart failure such as ischemic heart disease, hypertension, and valvular heart disease.
• Treat other non cardiac diseases that might contribute to the symptoms of heart failure such as diabetes and hyperthyroidism.
• Treat with a low salt diet
• Follow the patient's weight to check for fluid overload
• Treat with vaccines for influenza and pneumococcus .

• Second, after diuretics are started or at the same time you can begin the use of an ACE inhibitors . An example would be to start lisinopril 5 mg Q day. Every one to two weeks, the dose would be escalated to achieve a target dose of 15 to 20 mg Q day. ACE inhibitors are initiated before a beta blocker because they achieved their hemodynamic effects more rapidly, and they are less likely to cause a decline in hemodynamic function. If an ACE inhibitor is not tolerated, then an angiotensin receptor blocker ARB is started.
• Third, once you have achieved a stable dose of a diuretic and an ACE inhibitor, then a beta blocker can be added and the dose titrated based upon the patient's tolerance.
• Fourth, the combination of hydralazine and a nitrate (particularly among black patients) can be added if the patient continues to have symptoms on an ACE inhibitor and a beta blocker.

Shown below is an image that summarizes the steps in the chronic management of patients with heart failure.

Management of chronic heart failure