My EM Notes

Heart Failure

HFrEF

Goal of Heart Failure Mx - to prescribe combination of all at low initial doses and titrate to target/max tolerated doses (with doubling of doses), one at a time :

euvolaemic

an angiotensin-converting enzyme (ACE) inhibitor, or if not tolerated, angiotensin receptor blocker (ARB) and
a heart failure beta blocker then add
a mineralocorticoid receptor antagonist (MRA)

hypervolaemic

an angiotensin-converting enzyme (ACE) inhibitor, or if not tolerated, angiotensin receptor blocker (ARB) and
a mineralocorticoid receptor antagonist (MRA) then when euvolaemic, add
a heart failure beta blocker

ACEi Angiotensin-converting enzyme inhibitors	initial	target
enalapril	2.5mg OD	20mg OD
lisinopril	2.5mg OD	50mg OD
perindopril	2.5mg OD	10mg OD
ramipril	2.5mg bd	5mg bd
ARB Angiotensin receptor blockers	initial	target
candesartan	4mg OD	32mg OD
irbesartan	75mg OD	300mg OD
losartan	25mg OD	100mg OD
valsartan	40mg bd	160mg bd
olmesartan	10mg OD	40mg OD
β blockers	initial	target
bisoprolol	1.25mg OD	10mg OD
carvedilol	3.125mg bd	50mg bd
nebivolol	1.25mg OD	10mg OD
MRA Mineralocorticoid receptor antagonists	initial	target
spironolactone	25mg OD	50mg OD
eplerenone	25mg OD	50mg OD
ARNI angiotensin receptor/neprilysin inhibitor	initial	target
sacubitril/valsartan	49/51 mg bd	97/103 mg bd
other	initial	target
ivabradine	5mg bd	7.5mg bd

STRATEGY:

double the dose of each, one at a time, every 2–4/52(except MRAs; up-titrated in 4–8/52), or as tolerated.
add the next drug before reaching target or maximum tolerated dose, eg, if the patient is euvolaemic, a heart failure beta blocker may be started before achieving target or maximum tolerated dose of an ACE inhibitor.
clinical and lab review every 1–2/52 after each medicine initiation and dose increase,

If symptoms persist, consider:

add hydralazine and nitrate (esp if Afro-Caribbean)
digoxin for those is sinus
for LVEF ≤ 35%, change ACE inhibitor (or ARB) to an angiotensin receptor-neprilysin inhibitor (ARNI).
for LVEF ≤ 35%, add ivabradine for sinus HR>75

Heart failure with preserved ejection fraction (HFpEF)

Clinical syndrome of signs and symptoms of HF as the result of high LV filling pressure despite normal or near normal LV ejection fraction (LVEF; ?50 percent). Most have normal LV volumes and an abnormal diastolic filling pattern.
There is no clear evidence that pharmacologic therapy, diet, or other therapies reduce the risk of mortality in patients with HFpEF
Condition commonly associated with HFpEF conditions are managed using approaches similar to those used to treat the general population or other forms of HF; there is no evidence for HFpEF-specific management of these conditions, including:
- HTN, atrial fibrillation (AF), coronary artery disease
- hyperlipidemia, obesity, anemia, diabetes mellitus, chronic kidney disease (CKD), and sleep-disordered breathing