Therapy of Heart Failure
Patient has Diagnosis of Heart Failure
Pharmacological Management
Fluid Retention
Atrial Fibrillation
Ace-Inhibitors
Angiotensin II
antagonists (ARB)
Beta-Blockers and
Ivabradine
Aldosterone
Antagonists
Underlying
Disorders
Diastolic Heart
Failure
Referral to Clinic
Removing excess fluid is an initial essential, aim to normalise JVP, and clear lungs.
Frusemide 40-80mg daily common OP doses. Watch U/E, BP and symptoms.
Controlling ventricular rate is also an initial essential, aim resting HR <70.
Digoxin 0.0625mg / 0.125mg / 0.25mg od po depending on renal function especially
used in acute setting.
As OP preferably use bisoprolol 2.5mg / 5mg / 10mg. Once HR controlled usually
stop digoxin. If beta-blocker fails in HR control continue / add digoxin.
Remember anticoagulation for stroke prevention. Warfarin to be used in HF and AF
unless contraindicated.
Essential therapy in LV systolic dysfunction. Titrate dose upwards at approx 2-4
week intervals, usually ramipril 2.5mg / 5mg / 10mg po od. Watch U/E and BP.
Use as alternative to ACE-I (usually cough), usually candesartan 4mg / 8mg / 16mg
Beta-Blockers routinely indicated in systolic dysfunction, (both in AF and SR).
eg: bisoprolol 2.5mg / 5mg / 10mg po od as tolerated.
Control of heart rate also important. In SR, if resting HR >74bpm despite optimal
beta-blocker, then add ivabradine 5mg bd po / 7.5mg bd po. Aim HR not >60 at rest.
In AF ivabradine is contra-indicated: use betablocker +/- digoxin as needed.
Moderate/severe LV systolic impairment: routinely add spironolactone 25mg od po.
Watch U/E especially hyperkalaemia
Use eplerenone 25mg od po if gynaecomastia, or within 3-14 days of acute MI
Need therapy in their own right – for example hypertension control and diabetes.
Secondary prevention for CAD: aspirin 75mg od and statin.
Clopidogrel 75mg od for 1 year post acute coronary syndrome and/or stenting.
Heart failure with normal ejection fraction. Diuretics and heart rate control as
needed, together with therapy of underlying disorders, most commonly
hypertension. No mandate for ACE-I, ARB, or aldosterone anatagonists, though often
used empirically.
All patients with heart failure should be referred to hospital clinic. [NICE 108].
All (new) patients with suspected heart failure refer via NTProBNP pathway via the
ICE_Desktop application.
Heart Failure Team Hampshire Hospitals Foundation Trust. V1 April 2012 Dr Barnaby Thwaites