Heart Failure

Symptom control

  • Diuretic
  • Digoxin [even if no AF]

Reduced mortality

  • ACEi [alternative ARB if intolerant]
  • B-Blocker
  • Spironolactone

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

  1. 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
  2. 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]
  3. Third line [worsening despite above]
    • Digoxin

New York Heart Association [NYHA] classification

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


About B-Blockers in heart failure

NICE guideline on heart failure