Heart Failure – MEDICATIONS
1. Phenotype definitions
- HFrEF — LVEF ≤ 40 %
- HFmrEF — LVEF 41–49 %
- HFpEF — LVEF ≥ 50 %
2. “Quadruple-Foundation” Therapy for HFrEF
| Pillar | First-choice drug(s) & Australian target dose* | Key monitoring & tips |
|---|---|---|
| 1. RAAS / ARN pathway blocker | • ACE-I: enalapril 20 mg bd, perindopril 4–8 mg bd • ARB (if ACE-I intolerant): candesartan 32 mg od • Preferred: ARNI sacubitril/valsartan 97/103 mg bd (start after 36-h ACE-I wash-out) | U&Es, eGFR, K⁺ at baseline → 1–2 wk post up-titration → q3–6 mths. Watch for cough (ACE-I) & angio-oedema (ARNI) |
| 2. β-blocker | bisoprolol 10 mg od; carvedilol 25 mg bd (50 mg if > 85 kg); metoprolol-CR 200 mg od; nebivolol 10 mg od (≥ 70 y) | Start when euvolaemic. Aim HR 50–60 bpm. Review HR/BP/congestion q2–4 wk during titration |
| 3. Mineralocorticoid receptor antagonist | spironolactone 25 → 50 mg od or eplerenone 50 mg od | K⁺/eGFR at 1 wk, 1 mth, 3 mth, then q3–4 mth. Halve dose if K⁺ > 5.5 mmol/L |
| 4. SGLT2-inhibitor | dapagliflozin 10 mg od -or- empagliflozin 10 mg od (no titration) | Educate re genital hygiene; hold during peri-op/DKA risk |
*Target = guideline-proven “event-reducing” dose; up-titrate q2 wk (ACE/ARB/ARNI) or q2–4 wk (β‐blocker) as tolerated.
PBS status (2025): ARNI & SGLT2-i listed for NYHA II–IV HFrEF; SGLT2-i reimbursed for all EF phenotypes.
3. Algorithmic Titration
- Day 0: Start ACE-I (or ARB) + β-blocker (low dose).
- Week 2–4: Double ACE-I; uptitrate β-blocker.
- Week 4: Switch ACE-I/ARB → ARNI if SBP ≥ 100 mmHg.
- Week 4–6: Add MRA once creatinine ≤ 221 µmol/L & K⁺ < 5.0 mmol/L.
- Within 6 wk: Start SGLT2-i (any eGFR ≥ 20).
- >6 wk: Consider add-ons (below) if still NYHA II–IV.
4. Key Add-On / Specialist Agents
| Drug | Start dose | Use when… | Pearls |
|---|---|---|---|
| Loop diuretic (furosemide) | 20–40 mg od/bd | Any congestion | Daily weight plan; flexible dosing |
| Thiazide (metolazone 2.5 mg prn) | 1–3 d pulses | Diuretic resistance | High hypo-Na⁺ risk |
| Ivabradine | 5 mg bd | Sinus HR ≥ 70 bpm, LVEF ≤ 35 % despite max β-blocker | Stop if AF/bradycardia < 50 bpm |
| Digoxin | 62.5–125 µg od | AF rate control or persistent symptoms | Aim level 0.5–0.9 ng/mL |
| Hydralazine 25 mg tds + ISDN 20 mg tds | ACE/ARB/ARNI not tolerated | Headache, hypotension | |
| IV iron (ferric carboxymaltose) | per weight | Ferritin < 100 µg/L or TSAT < 20 % | Re-check iron @ 3 mth |
| Devices | ICD (EF ≤ 35 %) ± CRT (QRS ≥ 130 ms, LBBB) | After ≥ 3 mths optimised meds | Reduces sudden death & HF admission |
5. HFpEF / HFmrEF Essentials
- Primary goals: relieve congestion, treat comorbidities (HTN, AF, IHD, obesity, CKD, OSA).
- Evidence-based options (2025):
- SGLT2-i 10 mg od → ↓ HF hospitalisations (DELIVER/EMPEROR-Preserved).
- Low-dose spironolactone 25 mg od → modest ↓ admissions (TOPCAT).
- Avoid over-diuresis; target SBP < 130 mmHg.
6. Routine Monitoring (minimum)
| Timing | Labs (U&Es, eGFR, K⁺) | Vitals & weight | Symptom review |
|---|---|---|---|
| Baseline | ✔ | ✔ | ✔ |
| 1–2 wk after EVERY drug start / up-titration | ✔ | ✔ | ✔ |
| 1, 3, 6 mth, then q6 mth (stable) | ✔ | ✔ | ✔ |
7. Vaccination & Lifestyle Checklist
- Influenza yearly; Pneumococcal: PCV 15/20 → PPSV23 per ATAGI.
- Sodium < 2 g/day; fluid 1.5–2 L if hyponatraemic.
- Enrol in cardiac rehab; moderate aerobic + resistance training.
8. Medicines to avoid / use with caution
- Salt- & water-retainers: NSAIDs (incl. COX-2), steroids, TZDs.
- Negative inotropes: verapamil, diltiazem, most class I anti-arrhythmics.
- Pro-arrhythmics / QT prolongers: sotalol, TCA, flecainide.
- Electrolyte interactions: non-K-sparing diuretics ± digoxin; hyper-K⁺ with ACE/ARB/ARNI + MRA.
- Screen OTC / herbal (St John’s wort, grapefruit) for CYP/P-gp effects.
9. Deprescribing in Palliative Phase
- Continue if tolerated: RAAS/ARNI, β-blocker, MRA, SGLT2-i (symptom stability).
- Consider stopping: statins, digoxin (if sinus rhythm), ICD shocks.
- Decisions via shared planning with patient, family, GP & cardiologist.
10. Memory Aids
Check K⁺ > 5.5? Halve MRA/ACE; K⁺ > 6? Stop MRA.
“4 pillars = ARNI–β-blocker–MRA–SGLT2”
Start low → double dose every 2 wk (if BP > 90 & labs stable).
| Drug | Indications | Mechanism | Adverse effects | Precautions |
| ACE inhibitors | First-line therapy when LVEF <40% | Reduces sodium reabsorption Reduces aldosterone | Hypotension Worsening renal function Hyperkalaemia Chronic cough Angioedema | Previous angioedema Other drugs that increase potassium |
| Angiotensin receptor antagonists (sartans) | If intolerant of ACE inhibitors | Reduces vasoconstriction Reduces sodium reabsorption Reduces aldosterone | Hypotension Worsening renal function Hyperkalaemia | Other drugs that increase potassium |
| Beta blockers | First-line therapy when LVEF <40% | Reduces sympathetic activity Has antiarrhythmic effects Reverses remodelling | Hypotension Bradycardia Fatigue Bronchospasm Impotence Worsening heart failure Masking hypoglycaemia | 2nd and 3rd degree heart block Asthma Chronic obstructive pulmonary disease – exclude significant reversibility |
| Aldosterone antagonists | If symptomatic despite ACE inhibitor and beta blocker and LVEF <40% | Is a weak diuretic Reduces effects of aldosterone | Hyperkalaemia Worsening renal function Hypotension Gynaecomastia (spironolactone) | Other drugs that increase potassium |
| Sacubitril with valsartan | Heart failure LVEF <35% In place of ACE inhibitor or angiotensin receptor antagonist | Causes vasodilation Reduces sympathetic activity Enhances diuresis | Angioedema Hypotension | Previous angioedema A 36-hour ACE inhibitor washout is an absolute requirement before starting |
| Diuretics | Relief of congestive symptoms | Reduces retention of sodium and water | Renal dysfunction Hypokalaemia Worsened gout | Other drugs that lower potassium |
| Ivabradine | Heart rate 77 beats/min or higher despite beta blocker, or intolerant to beta blocker Sinus rhythm | Reduces heart rate in sinus rhythm | Visual disturbances (phosphenes) Headache Bradycardia Atrial fibrillation | 3rd degree atrioventricular block Sinoatrial blockStop if atrial fibrillation developsProlonged QT syndrome |
| Digoxin | Heart failure in sinus rhythm with symptoms despite ACE inhibitor, beta blocker, aldosterone antagonist, diureticAtrial fibrillation | Is a weak positive inotrope Reduces heart rate Increases vagal tone | Bradycardia Digoxin toxicity | Narrow therapeutic range requires monitoring Interacting drugs Impaired renal function |