Mount Carmel Health Partners Clinical Guidelines Heart Failure | Page 4

Step Four: Pharmacological Therapy (continued)
Digitalis Glycosides
• May be considered in patients with persistent and/or severe symptoms that have not responded symptomatically to treatment with
diuretics, ACEI, ARB, and beta-blockers.
• Routinely prescribed in patients with HF and chronic atrial fibrillation.
• Is not indicated as primary therapy for stabilization of patients with an acute exacerbation of HF.
• Should not be used with patients who have significant sinus or atrioventricular block unless the block has been treated with a permanent
pacemaker.
• Use caution in patients who are taking drugs associated with depression of sinus atrioventricular nodal functions.
• Use caution in patients post-myocardial infarction or not at all, especially if ischemia is present.
• If patient is 70 years of age or older, low doses (not greater than 0.125 mg daily or every other day) should be used.
Hydralazine and Isosorbide Dinitrate
• A significant benefit has been shown by the addition of hydralazine and Isosorbide Dinitrate to standard therapy with an ACEI and/or beta-blocker
in the African American population.
• Used for patients with more severe symptoms of HF and ACEI or ARB intolerance, hypotension, or renal insufficiency.
• Can be used for patients with reduced LVEF who are already taking an ACEI and a beta-blocker and who have persistent symptoms.
Aldosterone Antagonist (Spironolactone)
• Use cautiously at a low dose for patients with moderate to severe HF symptoms and recent decompensation of LF dysfunction early after MI.
• Should not be administered to patients with a baseline serum potassium of 5 mEq/L; patients should have no history of hyperkalemia.
• Not recommended in patient with serum creatinine > 2.5 or creatinine clearance less than 30 mL/min.
• Potassium levels and renal function should be checked in 3 days and at 1 week after initiating therapy and at least monthly for the first three
months.
• Combination of an ACEI, an ARB, and an aldosterone antagonist should be considered for NYHA Class II-IV . (Class I - Level A recommendation:
creatinine clearance greater than 30 and potassium less than 5 mEq/L.
• Aldosterone antagonists (selective) are weak diuretics that reduce mortality and risk of sudden death by blocking the effects of aldosterone.
Recommended in NYHA Class II - VI patients with LVEF less than 35% or following an acute myocardial infarction and LVEF less than 40% (both
Class I indications).
Pharmacologic Treatment for Stage C HRrEF
HFrEF Stage C
NYHA Class I - IV
Treatment:
Evaluation
Treatment
Class I, LOE A
ACEI or ARB or ARNI
AND
Beta Blocker
For all volume
overload,
NYHA class II-IV
patients For persistently
symptomatic
African Americans,
NYHA class III-IV For NYHA class II-IV
patients.
Provided estimated
creatinine >30 mL/min
and K+ <5.0 mEq/dL
Add Add Add
Class I, LOE C
Loop Diuretics Class I, LOE A
Hydral-Nitrates Class I, LOE A
Aldosterone
Antagonist
Heart Failure - 4