Congestive heart failure pharmacotherapy: Difference between revisions

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! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 AHA/ACC Guideline
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 AHA/ACC Guideline<ref name="pmid33755495">{{cite journal |vauthors=Bozkurt B, Hershberger RE, Butler J, Grady KL, Heidenreich PA, Isler ML, Kirklin JK, Weintraub WS |title=2021 ACC/AHA Key Data Elements and Definitions for Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Clinical Data Standards for Heart Failure) |journal=Circ Cardiovasc Qual Outcomes |volume=14 |issue=4 |pages=e000102 |date=April 2021 |pmid=33755495 |pmc=8059763 |doi=10.1161/HCQ.0000000000000102 |url=}}</ref>
 
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Revision as of 18:40, 4 February 2022

Congestive Heart Failure Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Systolic Dysfunction
Diastolic Dysfunction
HFpEF
HFrEF

Causes

Differentiating Congestive heart failure from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Clinical Assessment

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

Cardiac MRI

Echocardiography

Exercise Stress Test

Myocardial Viability Studies

Cardiac Catheterization

Other Imaging Studies

Other Diagnostic Studies

Treatment

Invasive Hemodynamic Monitoring

Medical Therapy:

Summary
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

Exercise Training

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

Congestive heart failure pharmacotherapy On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Congestive heart failure pharmacotherapy

CDC on Congestive heart failure pharmacotherapy

Congestive heart failure pharmacotherapy in the news

Blogs on Congestive heart failure pharmacotherapy

Directions to Hospitals Treating Congestive heart failure pharmacotherapy

Risk calculators and risk factors for Congestive heart failure pharmacotherapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Seyedmahdi Pahlavani, M.D. [3]

Overview

The following table summarized the stepwise treatment for heart failure.

Congestive heart failure treatment summary based on 2021 AHA/ACC Guideline

[1]

Pathophysiology Treatment
Renin-angiotensin-aldosterone system ARNIs/ACEIs/ARBs, aldosterone antagonist
Sympathetic nervous system Beta-blockers
Natriuretic and other vasodilator peptides Neprilysin inhibitor (ARNI)
Sodium-glucose cotransporter-2 SGLT2 inhibitors
Balanced vasodilation and oxidative stress modulation Hydralazine/Isosorbide dinitrate
Elevated heart rate Betablocker, Ivabradine
Guanylyl cyclase Soluble guanylyl cyclase stimulator
Relief of congestion Diuretic
Ventricul;ar arrhythmia Implantable cardioverter defibrilator
Ventricular dyssynchrony due to conduction abnormalities Cardiac resynchronization therapy
Mitral regurgitation Surgical or percutaneous Mitral repair
Reduced aerobic capacity Aerobic exercise training
The above table adopted from 2021 AHA/ACC Guideline

Treatment Algorithm for Guideline-Directed Medical Therapy Including Novel Therapies

 
 
 
 
 
 
 
 
 
Heart failure reduced EF, stage C, treatment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ARNI, ACEI, ARB
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
For patients with eGFR≥ 30 mL/min/1.73m² or creatinine≤ 2.5 mg/dL in males or ≤2 mg/dL in females or K≤ 5 mEq/L, NYHA 2-4
 
For patients with eGFR criteria, NYHA 2-4
 
For patients with persistent volume overload, NYHA 2-4
 
For symptomatic black patients despite receiving ARNI, betablocker,aldosterone antagonist, SGLT2 inhibitor, NYHA 3-4
 
For patients with resting HR>70/min despite maximum tolerated betablocker dose, sinus rhythm, NYHA 2-3
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Add
 
 
Add
 
Titrate
 
Add
 
Add
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Aldosterone antagonist
 
 
SGLT2 inhibitor
 
Diuretic agents
 
Hydralazine + Isosorbide dinitrate
 
Ivabradine
 
 
The above algorithm adopted from 2021 AHA/ACC Guideline










 
 
 
ACEI, ARB
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Starting in patient if ARNI is not accessible
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dosage initiation based on indication
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Increasing dose every 2 weeks until achieving target dose or maximum tolerance and monitoring of blood pressure, renal function, potassium after initiation and during titration
 
 
 


 
 
 
ARNI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initiation after 36 hours of discontinuing ACEI, if the patient is on ACEI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dosage initiation based on indication
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
24/26 mg twice daily if the patient is taking enalapril≤ 10 mg/day or valsartan≤ 160 mg/day
 
 
 
49/51 mg twice daily if the patient is taking enalapril> 10 mg/day or valsartan > 160 mg/day
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
In 2 weeks assessment about tolerance, blood pressure, electrolytes, renal function and dosage titration to target of 97/103 mg twice daily
 
 
 
 
 
 
 
 





 
 
 
Diuretics
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initiation loop diuretic dose based on renal function, previous use of diuretics
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Titration dose until recovery of congestion, reducing dose in concomitant administration of ACEI, ARB, ARNI, monitoring blood pressure, renal function, electrolytes after initiation and during titration dose
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
In high dose of loop diuterics (80 mg furosemide twice daily), Considering other type of loop diuretics or adding thiazide to loop diuretic by monitoring of blood pressure, renal function, electrolytes after initiation dose or during titration
 
 
 


 
 
 
SGLT2 inhibitor
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dosage initiation based on indication
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initiation dapaglifelozin in eGFR≥ 30 mL/min/1.73 m², and empagliflozin in eGFR≥ 20 mL/ min/1.73 m²
 
 
 







 
 
 
Betablocker
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dosage initiation based on indication
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dosage titration every two weeks until achieving target dose or maximum tolerance, monitoring heart rate , blood pressure after initiation and during titration
 
 
 


 
 
 
Aldosterone antagonist
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dosage initiation based on indication
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Increase dose every 2 weeks up to maximum dose or achieving tolerated dose, monitoring electrolytes and renal function at 2-3 days following initiation then 7 days after initiation or titration, then monthly for 3 months and every 3 months afterward, clinical status monitoring
 
 
 


 
 
 
Hydralazine, isosorbide dinitrate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Increase dose every 2 weeks until target dose or achieving tolerated dose with monitoring of blood pressure
 
 
 



Sacubitril/Valsartan Ivabradine SGLT2 Inhibitors
Contraindications Contraindications Contraindications
Causions
  • Renal impairment:
    Mild-to-moderate (eGFR 30-59 mL/ min/1.73 m2): no starting dose adjustment required
  • Severe (eGFR <30 mL/min/ 1.73 m2):
    Reduce starting dose to 24/26 mg twice daily,
    Double the dose every 2–4 weeks to target maintenance dose of 97/103 mg twice daily, as tolerated
  • Hepatic impairment:
    Mild (Child-Pugh A): no starting dose adjustment required
    Moderate (Child-Pugh B):
    Reduce starting dose to 24/26 mg twice daily
    Double the dose every 2–4 weeks to target maintenance dose of 97/103 mg twice daily, as tolerated
  • Renal artery stenosis
  • Systolic blood pressure <100 mm Hg
  • Volume depletion
Causions Causions

For prevention of ketoacidosis in patients with diabetes:

erythema, or swelling in the genital or perineal area, along with fever or malaise

The above table adopted from 2021 AHA/ACC Guideline[1]



 
 
 
Ivabradine
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Given Betablocker by maximum tolerable dose, sinus rhythm on ECG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Starting dose
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Age ≥ 75 years, 2.5 mg twice daily with food
 
 
 
Age <75 years, 5 mg twice daily with food
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluation of heart rate in 2-4 weeks
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Heart rate < 50 beats /min or symptoms of bradycardia
 
Heart rate 50-60 beats/ min
 
Heart rate>60 beats /min
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Reduced dose 2.5 mg twice daily with food, or discontinued if already on 2.5 mg twice daily
 
Maintaing current dose with monitoring heart rate
 
Increased dose by 2.5 mg twice daily until maximum dose of 7.5 mg twice daily, monitoring heart rate
 

References

  1. 1.0 1.1 Bozkurt B, Hershberger RE, Butler J, Grady KL, Heidenreich PA, Isler ML, Kirklin JK, Weintraub WS (April 2021). "2021 ACC/AHA Key Data Elements and Definitions for Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Clinical Data Standards for Heart Failure)". Circ Cardiovasc Qual Outcomes. 14 (4): e000102. doi:10.1161/HCQ.0000000000000102. PMC 8059763 Check |pmc= value (help). PMID 33755495 Check |pmid= value (help).

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