Congestive heart failure pharmacotherapy

Congestive Heart Failure Microchapters
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Pathophysiology Systolic Dysfunction Diastolic Dysfunction HFpEF HFrEF
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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
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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

2021 ACC/AHA Guideline for optimization of heart failure with Reduced Ejection Fraction treatment

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

• Indications for use of an ARNI

  Heart failure reduced EF (HFrEF) (LVEF ≤ 40%)

  NYHA 2-4 heart failure

  Use in place of ACEI or ARB for combination therapy of heart failure

• Indications for Use of Ivabradine

  Heart failure reduced EF (EF≤ 35%)

  On maximum tolerated dose of beta-blocker

  Sinus rhythm with a resting heart rate ≥ 70 beats/min

  NYHA class II or III HF

• Indications for Use of an SGLT2 Inhibitor

  HFrEF (EF ≤40%) with or without diabetes

  NYHA class II–IV HF

  Combined with other treatment of heart failure

• Dose adjustment of sacubitril-valsartan

  49/51 twice daily:

  Previous use of high dose of ACEI or ARB: valsartan 160 mg daily or enalapril 10 mg daily

  24/46 mg twice daily:

  valsartan<160 mg daily, enalapril < 10 mg daily

  No previous use of ACEI or ARB

  Severe renal impairment (eGFR <30 mL/min/1.73 m2)

  Moderate hepatic impairment (Child-Pugh Class B)

  Elderly (age ≥75 years)

Ivabradine

Given Betablocker by maximum tolerable dose, sinus rhythm on ECG

Starting dose

Age ≥ 75 years, 2.5 mg twice daily with food

Age <75 years, 5 mg twice daily with food

Evaluation of heart rate in 2-4 weeks

Heart rate < 50 beats /min or symptoms of bradycardia

Heart rate 50-60 beats/ min

Heart rate>60 beats /min

Reduced dose 2.5 mg twice daily with food, or discontinued if already on 2.5 mg twice daily

Maintaing current dose with monitoring heart rate

Increased dose by 2.5 mg twice daily until maximum dose of 7.5 mg twice daily, monitoring heart rate

	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