Mount Carmel Health Partners Clinical Guidelines Heart Failure | Page 3

Step Four: Pharmacological Therapy
Routine medications used in combination include:
• Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker or angiotesnsin receptor-neprilysin inhibitor
• Beta-blocker
• Diuretic
• Digoxin, spironolactone, hydralazine, isosorbide and ivabradine may also be added
Medication to Avoid in Heart Failure Patients
• Verapamil
• Nifedipine
• Non steroidal anti-inflammatory drugs (NSAIDs)
• Trimethoprim-sulfamethoxazole
• Diltiazem
• Cilostazol
• Piogliazone
• Terfendaine
Angiotensin-Converting Enzyme Inhibitor (ACEI)
• Recommended in all patients with heart failure with reduced ejection fraction
• Can be used interchangeably.
• Initiate at low doses and gradually increase as lower doses are tolerated; titrate to a specific goal as long as the patient can tolerate it.
• Renal function and serum potassium should be assessed after initiation, within 1 to 2 weeks, and at any dosage change.
• Contraindications for ACEI:
◦ Life-threatening adverse reactions: angioedema, anuric renal failure
◦ Pregnancy
• ACEI should still be used for patients with the following conditions but with caution:
◦ Low systemic blood pressure (systolic blood pressure less than 90 mmHg)
◦ Acutely increased serum levels of creatinine (greater than 3 mg/dL)
◦ Bilateral renal stenosis
Angiotensin Receptor Blocker (ARB)
• Candesartan and valsartan are indicated for HF.
• Losartan also commonly used.
• Recommended for patients with symptoms of HF and left ventricular ejection fraction (LVEF) of ≤ 40% who are unable to tolerate ACEI as the
first-line therapy; recommended for patients that cannot tolerate an ACEI due to cough.
• Blood pressure, renal function, and potassium should be reassessed within 1 to 2 weeks after initiation and monitored closely thereafter.
• Titration is achieved by doubling the doses.
• ARBs have all the same considerations listed for ACEIs.
Angiotensin Receptor— Neprilsyin Inhibitor (ARNI)
• Currently available as valsrtan/sacubitril.
• Recommended in patients with heart failure with reduced ejection fraction NYHA class II or III.
• Not to be administered concomitantly with ACEI or within 36 hours of switching to or from ACEI.
• Not to be administered if history of angioedema.
• ARNIs also have same considerations as ARBs.
• Use pro-BNP for testing.
Beta-Blocker
• Carvedilol, metoprolol succinate (not metoprolol tartrate), and bisoprolol are indicated for HF.
• Act to inhibit the adverse effects of the sympathetic nervous system in patients with HF.
• Recommend for all patients with stable HF due to reduced LVEF, unless there is a contraindication.
• As soon as LV dysfunction is diagnosed, beta-blocker initiation should begin.
• Patients with current or recent history of fluid retention should not be prescribed beta-blockers without a diuretic because diuretics are needed
to maintain sodium and fluid balance and prevent the exacerbation of fluid retention that can accompany the initiation of beta-blocker therapy.
• Patients should have no or minimal evidence of fluid overload or volume depletion and should not have required recent treatment with an
intravenous positive inotropic agent.
• May be considered in patients with reactive airway disease or symptomatic bradycardia, but should be used with great caution or not at all in
patients with persistent symptoms of either condition.
• Titration to goal dose as patient tolerates.
Diuretics
• Loop diuretics used: furosemide, torsemide, bumetanide, ethacrynic acid (only for patients with sulfa allergies).
• Work to increase urinary sodium excretion and decrease physical signs of fluid retention in patients with HF.
• Should be used for all patients with evidence of fluid retention unless contraindicated.
• Produce symptomatic benefits more rapidly than any other drug for HF.
• Appropriate use of diuretics is a key element for the treatment of HF.
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Heart Failure - 3