Congestive heart failure Pharmacological treatments for patients with heart failure with reduced ejection fraction

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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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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
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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]; Associate Editor(s)-in-Chief: Mitra Chitsazan, M.D.[2]

Overview

The major goals of pharmacologic treatment for patients with HFrEF are reducing mortality, reducing the risk of repeated hospitalizations due to worsening HF, and improving clinical status, functional capacity, and quality of life. The mainstay of treatment for HFrEF is the modulation of the [[renin-angiotensin-aldosterone] system] (RAAS) and sympathetic nervous system.

Therapuetic approach

• The major goals of pharmacologic treatment for patients with HFrEF are:
  • 1) Reducing mortality (either all-cause or cardiovascular)
  • 2) Reducing the risk of repeated hospitalizations due to worsening HF
  • 3) Improving clinical status, functional capacity, and quality of life
• The cornerstone of pharmacologic management of HFrEF is the modulation of the [[renin-angiotensin-aldosterone] system] (RAAS) and sympathetic nervous system (i.e., neurohormonal blockade).

For all patients: To reduce mortality

• Angiotensin-converting enzyme inhibitors (ACE-I) or an angiotensin receptor-neprilysin inhibitor (ARNI), beta-blockers, and mineralocorticoid receptor antagonists (MRA) reduce mortality, reduce the risk of repeated HF hospitalizations, and improve symptoms in patients with HFrEF.
• Thus, a combination of an ACE-I/ARNI, a beta-blocker, and an MRA is recommended as class I therapies for all HFrEF patients unless they are contraindicated or not tolerated. These drugs should be uptitrated to the doses used in the clinical trials or to maximally tolerated doses.
• Unless contraindicated or not tolerated, the sodium-glucose co-transporter 2 (SGLT2) inhibitors (dapagliflozin and empagliflozin) are also recommended for all HFrEF patients and should be added to pharmacotherapy of HFrEF patients that are already taking an ACE-I/ARNI, a beta-blocker, and an MRA, regardless of diabetes status.

For all patients with HFrEF (LVEF<40%)

ACE-I/ARNI

BB

MRA

SGLT2i

Captopril Enalapril Lisinopril Ramipril

Sacubitrl/valsartan

Bisoprolol Carvedilol Metoprolol succinate Nebivolol

Eplerenone Spironolactone

Dapagliflozin Empagliflozin

For selected patients: To reduce mortality/HF hospitalization

Diuretics

• Diuretics reduce HF symptoms and HF hospitalization and improve exercise capacity. However, their effects on mortality are remained to be elucidated.
• Loop diuretics can reduce volume overload and reduce shortness of breath and edema, and thus are recommended in patients with signs or symptoms of volume overload.
• A rise in BUN and Cr may reflect a reduction in renal perfusion, and further diuresis should only be undertaken with careful monitoring of renal function.

There are three major types of diuretics, loop diuretics, thiazides and potassium-sparing diuretics.  Diuretics rapidly improve the symptoms of heart failure (within hours to days).  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 be a better choice due to its more predictable absorption.  Once a day dosing of a given diuretic is preferred to twice a day dosing at a lower dose.  A rise in BUN and Cr may reflect a reduction in renal perfusion, and further diuresis should only be undertaken with careful monitoring of renal function.  The patient should weigh themselves each morning at the same time on the same scale, and the diuretic dosing should be adjusted to maintain a constant weight.  Given the risk of hypokalemia or hyperkalemia, the blood level of electrolyes should be checked regularly.

• Simultaneous With Initiating Diuresis

• 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