Heart Failure: Pharmacologic Management


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Diuretics can often be reduced as doses of neurohormonal blockers are increased. A small dose of a thiazide or a potassium-sparing diuretic can be added to furosemide frusemide or bumetanide for a short period. This has a synergistic diuretic effect for patients with peripheral oedema resistant to treatment with a loop diuretic. Renal function and potassium need to be closely monitored. A raised resting heart rate is a marker of cardiovascular risk. Ivabradine can only be used in sinus rhythm. It does not affect blood pressure, intracardiac conduction or myocardial contractility.

It may cause visual symptoms, including flashing lights, which are not associated with retinal damage, and which usually resolve spontaneously. Stop ivabradine if atrial fibrillation develops.

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Digoxin is useful for symptomatic control of heart failure in sinus rhythm, but only after therapy with an ACE inhibitor, beta blocker, aldosterone antagonist and diuretic has been optimised. It is a weak positive inotrope and increases vagal tone. In atrial fibrillation digoxin slows the heart rate by reducing atrioventricular nodal conduction. High-dose hydralazine is an arterial vasodilator. Isosorbide dinitrate is predominantly a venodilator. The combination can be used with a beta blocker if the patient is intolerant of ACE inhibitors and sartans. Specialist advice should be sought.

This reduces mortality and heart failure hospitalisations and improves symptoms.

Management of heart failure

Compared to those with a reduced ejection fraction, patients with heart failure with preserved ejection fraction are older, more likely to be female and to have hypertension, atrial fibrillation, diabetes or obesity. The mechanism probably relates to a combination of pathophysiological processes including increased myocardial stiffness, abnormal myocardial relaxation and increased arterial stiffness.


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No drug has been shown to improve survival, 35 however recent data suggest that in a subset of patients with heart failure and preserved ejection fraction, aldosterone antagonists may improve clinical outcomes. Diuretics should be used judiciously and over-diuresis avoided. Treatment should focus on aggressive control of concurrent conditions particularly hypertension.

Atrial fibrillation should be managed according to guidelines, using a rate control strategy and anticoagulation initially, with a trial of rhythm control for persistent symptoms. Myocardial ischaemia, obesity and anaemia should be addressed. Exercise training can improve quality of life.

Substantial improvements in symptoms are seen after starting drug therapy and often patients will feel back to normal. Left ventricular ejection fraction can sometimes return to normal or close to the normal range. Drugs that confer a survival benefit, in particular ACE inhibitors and beta blockers, should not be stopped, as this may lead to a recurrence of heart failure. When the goals of treatment move to palliation and symptom control, ACE inhibitors, beta blockers and aldosterone antagonists should be continued if possible, as they improve symptoms.

Down-titration of doses may be needed if hypotension or issues with renal function and electrolytes occur. Statins and digoxin if not being used for atrial fibrillation can be withdrawn. Deactivation of an implantable cardioverter defibrillator should be considered in a patient entering the palliative phase of their illness, or in a patient making an informed end-of-life decision.


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Many drugs have been shown to exacerbate heart failure. Non-dihydropyridine calcium channel blockers verapamil and diltiazem should be strictly avoided in heart failure with reduced ejection fraction due to their negative inotropic effect. Antiarrhythmic drugs except beta blockers and amiodarone and tricyclic antidepressants have pro-arrhythmic potential. Corticosteroids result in salt and water retention.

Pioglitazone and some dipeptidyl peptidase 4 DPP 4 inhibitors may increase the risk of heart failure. Non-potassium sparing diuretics can contribute to digoxin toxicity by causing hypokalaemia, and digoxin concentrations can be increased by amiodarone and spironolactone. These should be avoided. The type of heart failure determines its treatment.

Echocardiography should be used to confirm the underlying aetiology. Patient education is key to successful management. ACE inhibitors and beta blockers are the cornerstone of therapy for heart failure with reduced ejection fraction. Aldosterone antagonists are added if the patient is still symptomatic.

These three drugs reduce mortality and morbidity. Digoxin and diuretics may also be useful if symptoms persist. The combination of valsartan with sacubitril is an evolving alternative to ACE inhibitors in heart failure with reduced ejection fraction. Drug doses need to be titrated to maximally tolerated doses to obtain the most benefit on symptoms and survival.

No drugs have been shown to improve survival in patients who have heart failure with preserved ejection fraction. Treatment should focus on related problems such as hypertension. Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise disclaims all liability including for negligence for any loss, damage or injury resulting from reliance on or use of this information. Read our full disclaimer.

This website uses cookies. Read our privacy policy. Skip to main content. Log in Log in All fields are required. Log in. Forgot password? Article Authors. SUMMARY The clinical diagnosis of heart failure should be confirmed by echocardiogram to determine the underlying mechanism and to measure the left ventricular ejection fraction.

Pathophysiology Heart failure is the end result of a number of different pathophysiological processes in which there is injury to the heart with loss or impairment of functioning myocardial cells. Ejection fraction Heart failure is often due to myocardial dysfunction and is broadly classified by left ventricular ejection fraction. Correcting the cause Underlying causes of heart failure need to be identified and managed.

Drug therapy for heart failure with reduced ejection fraction The goal of management of heart failure with reduced ejection fraction is to control symptoms, prevent progression of left ventricular dysfunction, decrease hospitalisation and improve survival. Table 1 - Drugs used in heart failure with reduced left ventricular ejection fraction.

Table 2 - Recommendedtarget doses. ACE inhibitors and angiotensin receptor antagonists ACE inhibitors are first-line therapy in heart failure with reduced ejection fraction and asymptomatic left-ventricular dysfunction.

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Beta blockers Beta blockers are another important first-line therapy for heart failure with reduced ejection fraction. Aldosterone antagonists Aldosterone antagonists improve survival across the full spectrum of heart failure with reduced ejection fraction. Sacubitril with valsartan Sacubitril with valsartan is a new combination which was shown to be superior to enalapril in a large head-to-head trial, with an absolute reduction of cardiovascular death and heart failure hospitalisation of 4.

Other drugs Other therapies can be added to the essential drugs for heart failure beta blockers, ACE inhibitors and aldosterone antagonists. Diuretics Loop diuretics are used by most patients at some stage for symptomatic control of heart failure. Ivabradine A raised resting heart rate is a marker of cardiovascular risk. Digoxin Digoxin is useful for symptomatic control of heart failure in sinus rhythm, but only after therapy with an ACE inhibitor, beta blocker, aldosterone antagonist and diuretic has been optimised.

Heart Failure - Clinical Presentation

Hydralazine plus isosorbide dinitrate High-dose hydralazine is an arterial vasodilator. Heart failure with preserved ejection fraction Compared to those with a reduced ejection fraction, patients with heart failure with preserved ejection fraction are older, more likely to be female and to have hypertension, atrial fibrillation, diabetes or obesity.

Related CE

Withdrawal of treatment Substantial improvements in symptoms are seen after starting drug therapy and often patients will feel back to normal. Drugs to avoid Many drugs have been shown to exacerbate heart failure. Conclusion The type of heart failure determines its treatment. Conflict of interest: none declared.

Heart Failure: Pharmacologic Management Heart Failure: Pharmacologic Management
Heart Failure: Pharmacologic Management Heart Failure: Pharmacologic Management
Heart Failure: Pharmacologic Management Heart Failure: Pharmacologic Management
Heart Failure: Pharmacologic Management Heart Failure: Pharmacologic Management
Heart Failure: Pharmacologic Management Heart Failure: Pharmacologic Management
Heart Failure: Pharmacologic Management Heart Failure: Pharmacologic Management
Heart Failure: Pharmacologic Management Heart Failure: Pharmacologic Management

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