Heart failure – QuickDoc.

Symptom control

Reduced mortality

Diuretic therapy

Loop diuretic [for LVF and peripheral oedema] [potent]
- [Furosemide] [initially low to medium dosage: 40 – 80mg OD] [Maintain 20 – 40mg OD or BD] [Resistant 80 – 120mg daily]
- [Bumetanide] [gm for gm, 40 X more potent than Furosemide] [better absorbed in HF – marginal clinical benefit]
- [Both equivalent in activity] [act within 1h] [last 6 hours] [can give twice in day and sleep not interfered]
- [Start low] [encourage self adjustment by weight, symptoms & signs]
Thiazide [for peripheral oedema] [moderately potent]
- [Act within 1-2h] [last for 12-24h] [administer early in day]
- [Bendroflumethiazide] [5-10mg daily or alternate days] [maintenance 5-10mg 1-3 times a week]
- [Chlortalidone] [Longer acting so more steady diuresis] [50-100mg daily-alternate days]

Left heart failure

First line [ACEi & B-Blocker]
- ACEi [or ARB] [or Hydralazine with nitrate if intolerant to ACEi or ARB – started by specialist]
  - Ramipril [1.25mg OD – increase 1-2w to 10mg daily (taken as 2 divided dosage) as tolerated – monitor every dose change with U&Es]
- B-Blocker [start low, titrate ever 2 weeks]
  - [Can potentially worsen HF] [If congested increase diuretic dose first and review]
  - Caverdilol [3.125 BD > 2.25mg BD > 12.5mg > BD 25mg BD @ 2w interval to max dose tolerated]
  - Bisoprolol [Increase from 1.25 OD > 2.5mg OD > 3.75mg OD every 1w] [then 5mg OD for 4w] [then 7.5mg OD for 4w] [then 10mg OD]
  - Titrate if: [not symptomatic bradycardia] [not congested] [not symptomatic hypotension]
  - HR < 50 & worsening symptom – half B-Blocker & review [consider ECG for heart block]
  - If symptomatic hypotensive – consider discontinuing vasodilators [e.g. nitrates] or reducing diuretic dose if not congested
  - Side effect [e.g. dizziness, tiredness] – often settle & rarely indication to reduce dosage of B-Blocker. Half if severe & review 2w.
  - Detailed guide
Second line [Add to above if symptomatic despite above optimal or if suitable – Started by specialist]
- Spironolactone [esp. if NYHA III-IV or MI within the last month] [25mg OD] [not recommended with ACEi or ARB]
- ARB [NYHA II-III] or… Hydralazine with nitrate [esp. If Afro-Caribbean or NYHA III-IV]
Third line [worsening despite above]
- Digoxin

New York Heart Association [NYHA] classification

[No limitation of physical activity] [ordinary physical activity does not cause fatigue, breathlessness or palpitation]
[Mild HF] [Slight limitation of physical activity] [Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, breathlessness or angina pectoris]
[Moderate HF] [Marked limitation of physical activity] [Comfortable at rest but less than ordinary activity will lead to symptoms]
[Severe HF] [Discomfort with all physical activity] [Symptoms at rest. Increased discomfort with any physical activity]

Links

About B-Blockers in heart failure