Congestive heart failure pharmacotherapy

Congestive Heart Failure Microchapters
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Patient Information
Overview
Historical Perspective
Classification
Pathophysiology Systolic Dysfunction Diastolic Dysfunction HFpEF HFrEF
Causes
Differentiating Congestive heart failure from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Clinical Assessment
History and Symptoms
Physical Examination
Laboratory Findings
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Exercise Stress Test
Myocardial Viability Studies
Cardiac Catheterization
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Treatment
Invasive Hemodynamic Monitoring
Medical Therapy:
Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF Diuretics ACE Inhibitors Angiotensin receptor blockers Aldosterone Antagonists Beta Blockers Ca Channel Blockers Nitrates Hydralazine Positive Inotropics Anticoagulants Angiotensin Receptor-Neprilysin Inhibitor Antiarrhythmic Drugs Nutritional Supplements Hormonal Therapies Drugs to Avoid Drug Interactions Treatment of underlying causes Associated conditions
Exercise Training
Surgical Therapy: Biventricular Pacing or Cardiac Resynchronization Therapy (CRT) Implantation of Intracardiac Defibrillator Ultrafiltration Cardiac Surgery Left Ventricular Assist Devices (LVADs) Cardiac Transplantation
ACC/AHA Guideline Recommendations Initial and Serial Evaluation of the HF Patient Hospitalized Patient Patients With a Prior MI Sudden Cardiac Death Prevention Surgical/Percutaneous/Transcather Interventional Treatments of HF Patients at high risk for developing heart failure (Stage A) Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B) Patients with current or prior symptoms of heart failure (Stage C) Patients with refractory end-stage heart failure (Stage D) Coordinating Care for Patients With Chronic HF Quality Metrics/Performance Measures
Implementation of Practice Guidelines
Congestive heart failure end-of-life considerations
Specific Groups: Special Populations Patients who have concomitant disorders Obstructive Sleep Apnea in the Patient with CHF NSTEMI with Heart Failure and Cardiogenic Shock
Congestive heart failure pharmacotherapy On the Web
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Congestive heart failure pharmacotherapy in the news
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Directions to Hospitals Treating Congestive heart failure pharmacotherapy
Risk calculators and risk factors for Congestive heart failure pharmacotherapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Overview

The following table summarized the stepwise treatment for heart failure.

Congestive heart failure treatment summary based on 2021 ACC/AHA Guideline

Pathophysiology	Treatment
Renin-angiotensin-aldosterone system	ARNIs/ACEIs/ARBs, aldosterone antagonist
Sympathetic nervous system	Beta-blockers
Natriuretic and other vasodilator peptides	Neprilysin inhibitor (ARNI)
Sodium-glucose cotransporter-2	SGLT2 inhibitors
Balanced vasodilation and oxidative stress modulation	Hydralazine/Isosorbide dinitrate
Elevated heart rate	Betablocker, Ivabradine
Guanylyl cyclase	Soluble guanylyl cyclase stimulator
Relief of congestion	Diuretic
Ventricul;ar arrhythmia	Implantable cardioverter defibrilator
Ventricular dyssynchrony due to conduction abnormalities	Cardiac resynchronization therapy
Mitral regurgitation	Surgical or percutaneous Mitral repair
Reduced aerobic capacity	Aerobic exercise training

Sacubitril/Valsartan	Ivabradine	SGLT2 Inhibitors
Contraindications Within 36 hours of ACEI use History of angioedema with or without an ACEI or ARB Pregnancy Lactation (no data) Severe hepatic impairment (Child-Pugh C) Concomitant aliskiren use in patients with diabetes Known hypersensitivity to either ARBs or ARNIs	Contraindications HFpEF Presence of angina with normal EF Hypersensitivity Severe hepatic impairment (Child-Pugh C) Acute decompensated HF Blood pressure <90/50 mm Hg Sick sinus syndrome without a pacemaker Sinoatrial node block 2nd or 3rd degree block without a pacemaker Resting heart rate <60 beats/min Persistent AF or atrial flutter Atrial pacemaker dependence	Contraindications Not approved for use in patients with type I diabetes due to increased risk of diabetic ketoacidosis Known hypersensitivity to drug Lactation (no data) On dialysis
Causions Renal impairment: Mild-to-moderate (eGFR 30-59 mL/ min/1.73 m2): no starting dose adjustment required Severe (eGFR <30 mL/min/ 1.73 m2): Reduce starting dose to 24/26 mg twice daily, Double the dose every 2–4 weeks to target maintenance dose of 97/103 mg twice daily, as tolerated Hepatic impairment: Mild (Child-Pugh A): no starting dose adjustment required Moderate (Child-Pugh B): Reduce starting dose to 24/26 mg twice daily Double the dose every 2–4 weeks to target maintenance dose of 97/103 mg twice daily, as tolerated Renal artery stenosis Systolic blood pressure <100 mm Hg Volume depletion	Causions Sinus node disease Cardiac conduction defects Prolonged QT interval	Causions For HF care, dapagliflozin in eGFR <30 mL/min/1.73 m2 For HF care, empagliflozin, in eGFR <20 mL/min/1.73 m2 Pregnancy Increased risk of mycotic genital infections May contribute to volume depletion, altering diuretic dose if applicable For prevention of ketoacidosis in patients with diabetes: Temporary discontinuation before scheduled surgery Assess patients who present with signs and symptoms of metabolic acidosis for ketoacidosis, regardless of blood glucose level For prevention of acute kidney injury and renal impairment: temporarily discontinuing in settings of reduced oral intake or fluid losses Urosepsis and pyelonephritis: evaluation for signs and symptoms of urinary tract infections and treatment Necrotizing fasciitis of the perineum (Fournier’s gangrene): rare, serious, life-threatening cases, assessment of pain or tenderness, erythema, or swelling in the genital or perineal area, along with fever or malaise

	Acute Decompensated	Chronic
HFpEF	Oxygen Diuretics Vasodilators ACE inhibitors	Hypertension control Diuretics
HFrEF	Oxygen Diuretics Vasodilators Inotropics	Diuretics ACE inhibitors and angiotensin receptor blocker (ARB) Beta blockers Aldostrone antagonists Combination of hydralazine and a nitrate Digoxin