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Heart failure - chronic - Management
What drug treatments should I consider in a person with heart failure and left ventricular systolic dysfunction?

  • To relieve symptoms of fluid overload, prescribe a diuretic.
    • Titrate the dose up or down according to symptoms; review the dose and adjust as necessary after introducing other drug treatments for heart failure.
  • To reduce morbidity and mortality, prescribe an angiotensin-converting enzyme (ACE) inhibitor and a beta-blocker.
    • Use clinical judgement when deciding which drug to start first. For example the preferred initial treatment might be:
      • A beta-blocker, if the person has angina.
      • An ACE inhibitor, if the person has diabetes.
      • An ACE inhibitor, if the person still has signs of fluid overload (treating a person with heart failure who still has fluid overload with a beta-blocker may make the symptoms of heart failure worse).
    • If the person has previously used an ACE inhibitor but was unable to tolerate this due to persistent troublesome cough, prescribe an angiotensin-II receptor antagonist (AIIRA).
    • If the person is taking a beta-blocker for another comorbidity (for example angina or hypertension), but this is not bisoprolol, carvedilol, or nebivolol, switch the person to one of these (licensed for use in heart failure).
  • Introduce one drug at a time, and once the person is stable on the first drug, add the second drug.
  • For example, if prescribing an ACE inhibitor first:
    • Prescribe a low dose and titrate upwards until the target dose or the highest tolerated dose is reached.
      • If the person is using high doses of a loop diuretic (equivalent to 80 mg furosemide or more), consider seeking specialist advice before starting treatment.
      • Monitor renal function and serum electrolytes before starting treatment, 1–2 weeks after starting treatment, and after each dose increase.
      • Do not increase the dose further if there is worsening renal function or hyperkalaemia (for more information, see managing abnormal results).
    • Once stable, add a beta-blocker, unless it is contraindicated (for example asthma, heart block, symptomatic hypotension, or chronic obstructive pulmonary disease with reversibility) or the person is known to be intolerant of beta-blockers.
      • Start at a low dose and titrate slowly upwards until the target dose or the highest tolerated dose is reached.
      • Monitor heart rate, blood pressure, and clinical status after each dose increase.
    • If prescribing an AIIRA instead of an ACE inhibitor, for advice on dosage, titration, and monitoring, see Managing AIIRAs in Prescribing information.
  • If the person is still symptomatic despite optimal treatment with an ACE inhibitor (or AIIRA) and beta-blocker:
    • Refer for specialist review and advice regarding the addition of further drug treatments.
    • Treatments which may be recommended by a specialist include an aldosterone antagonist, an AIIRA in combination with an ACE inhibitor, hydralazine in combination with a nitrate (especially if the person is of Afro–Caribbean origin), or digoxin.
  • In all people, consider whether an antiplatelet drug and a statin are indicated.
    • An antiplatelet drug is indicated if the person has atherosclerotic arterial disease (such as coronary heart disease, stroke or transient ischaemic attack, or peripheral arterial disease). See the CKS topic on Antiplatelet treatment.
    • A statin is indicated if the person has atherosclerotic arterial disease or has a 10-year risk of a cardiovascular event which is 20% or more. See the CKS topics on CVD risk assessment and management and Lipid modification - CVD prevention for more information.
  • Consider if anticoagulation therapy with warfarin is indicated; this includes people with:
    • Heart failure and atrial fibrillation.
    • Heart failure who are in sinus rhythm and have a history of thromboembolism, left ventricular aneurysm, or intracardiac thrombus.
  • Review other medications that may affect the person's heart failure status, such as nonsteroidal anti-inflammatory drugs (associated with fluid retention and renal toxicity), calcium-channel blockers (may cause fluid retention and have no mortality benefit), or antiarrhythmics.
  • Consider comorbidities which may influence the treatment of heart failure.

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