Initiate Heart Failure Management
Pharmacologic Management of Heart Failure:
Medication |
Beneficial Subsets |
ACE Inhibitors |
NYHA Class I-IV |
ACE inhibitors slow disease progression, improve exercise capacity and decrease hospitalization and mortality.
[Conclusion Grade I: See Conclusion Grading Worksheet D - Annotations # 6 and 13 (ACE Inhibitors) in the original guideline document.]
|
Angiotensin II Receptor Antagonists |
NYHA Class I-IV. Reduce afterload and improve cardiac output. Can be used for patients with ACE inhibitor cough. |
Hydralazine/Isosorbide Dinitrate |
Patients intolerant to ACE inhibitors |
Diuretics |
Fluid overload (edema, ascites, dyspnea, weight gain) |
Aldosterone Antagonists |
NYHA Class III-IV |
Digoxin |
NYHA Class II-IV; patients with atrial fibrillation; patients with S3 gallop, left ventricular (LV) dilatation, high filling pressures |
Digitalis improves symptoms, exercise tolerance, and quality of life, but neither increases nor decreases mortality.
[Conclusion Grade I: See Conclusion Grading Worksheet E - Annotations #6 and 13 (Digitalis) in the original guideline document.]
|
Beta-Blockers |
Stable NYHA Class I-IV |
Refer to the original guideline document for information on initial daily doses and optimal (target) daily doses.
Treatment of Systolic Dysfunction
The cornerstone of treatment is the use of beta-blockers and ACE inhibitors. Certain beta-blocking medications have been shown to improve clinical symptoms and ventricular function in patients with systolic dysfunction.
Beta-blockers decrease hospitalizations and mortality and have objective beneficial effect on measures of exercise duration. [Conclusion Grade I: See Conclusion Grading Worksheet C – Annotation #6 and 14 (Beta-blockers and Exercise) in the original guideline document]
ACE inhibitors prolong life in patients with HF symptoms and EF less than 35% and reduce symptom development in asymptomatic patients with EF less than 35%.
There is also a mortality benefit in the use of ACE inhibitors in patients with recent myocardial infarction and asymptomatic EF less than 40%.
ACE inhibitors slow disease progression, improve exercise capacity, and decrease hospitalizations and mortality. [Conclusion Grade I: See Conclusion Grading Worksheet D - Annotations #6 and 13 (ACE Inhibitors) in the original guideline document]
Refer to the original guideline for additional information on treatment of systolic dysfunction.
Evidence supporting this recommendation is of classes: A, D
Treatment of Heart failure with Preserved Systolic Function
For the management of preserved systolic function it is particularly important to address the underlying etiology. Ischemia and hypertension must be optimally controlled. Pericardial disease must be specifically treated if present. Control of atrial tachyarrhythmias may be of particular importance since these patients need adequate time for diastolic filling and they tolerate tachycardias poorly. Beta-blockers may be of value to slow the heart rate and allow a longer time interval for diastolic filling.
In general, drugs used to treat systolic dysfunction (ACE, ARBs, diuretics, beta-blockers) are generally found to be effective in patients with heart failure with preserved systolic function.
Diuretics may be helpful to control volume overload and edema. They should be used in the lowest dose needed since excessive diuresis may cause orthostatic hypotension or prerenal azotemia. Arteriolar vasodilators or venodilators should be used with caution as they may cause serious hypotension.
Patients with hypertrophic cardiomyopathy should be identified and may benefit from genetic counseling. Patients with hypertrophic cardiomyopathy may benefit from beta-blockers to slow heart rate. Some may benefit from verapamil or disopyramide if beta-blockers are not effective. In cases of significant intracavitary pressure gradients, dual chamber pacing or septal myectomy surgery may be indicated.
Particular attention must be given to the control of atrial tachyarrhythmias. Care should be taken to avoid venodilators and arterial vasodilators.
See Annotation #13, "Pharmacologic Management" for inpatient medications.
Evidence supporting this recommendation is of classes: A, C
For patients with predominant heart failure with preserved systolic function:
Treat specific contributing causes:
- Hypertension (goal is blood pressure of 130/85 mm Hg). See also the NGC summary of the ICSI guideline Hypertension Diagnosis and Treatment.
- Ischemic heart disease
- Hypertrophic cardiomyopathy - consider referral to subspecialist (for verapamil, disopyramide, surgical myectomy, pacemaker)
- Constrictive pericarditis
Pharmacologic Management for Preserved Systolic Function:
Medication |
Beneficial Subsets |
ACE Inhibitors |
NYHA Class I-IV. Use with caution as they may cause serious hypotension. |
Angiotensin II Receptor Antagonists |
NYHA Class I-IV. Reduce afterload and improve cardiac output. Can be used for patients with ACE inhibitor cough. |
Diuretics |
Use with caution to manage fluid retention but not at doses which cause significant orthostatic hypotension or prerenal azotemia. |
Beta Blockers |
Patients with atrial fibrillation |
See original guideline document for dosing comments.
(See also Annotation #13 for further description of pharmacologic management.)