Heart Failure Medicine Initiation

Heart failure medicine initiation begins after the diagnosis is confirmed by symptoms and signs, raised natriuretic peptides and echocardiography. Heart failure with reduced ejection fraction, with an ejection fraction of 40% or under, is treated with four drug classes started within weeks. Heart failure with mildly reduced or preserved ejection fraction is treated mainly with an SGLT2 inhibitor and diuretics for congestion. Start low, correct the cause and congestion, and build up as pressure, heart rate, potassium and creatinine allow.

Baseline. Record weight, blood pressure, heart rate, rhythm, creatinine, eGFR, potassium, sodium, haemoglobin, ferritin, transferrin saturation, liver tests, thyroid function and glucose.

Cause. In East Africa, hypertensive heart disease, rheumatic valve disease and peripartum cardiomyopathy are common, and valve disease or arrhythmia may need specialist treatment as well.

Congestion. Furosemide 40 mg orally once daily (diuretic naive), increased to relieve congestion, then lowered to the least dose that keeps weight stable.

SGLT2 inhibitor. Dapagliflozin 10 mg or empagliflozin 10 mg orally once daily. Start when eGFR is 20 mL/min/1.73 m2 or over. No titration. Stop during acute illness with poor intake.

ACE inhibitor. Ramipril 1.25 to 2.5 mg orally once daily, target 10 mg daily (or 5 mg twice daily). Alternatively lisinopril 2.5 mg once daily, target 20 to 35 mg, or enalapril 2.5 mg twice daily, target 10 to 20 mg twice daily. Switch to an angiotensin receptor blocker for cough: candesartan 4 mg once daily, target 32 mg, or valsartan 40 mg twice daily, target 160 mg twice daily.

Beta blocker. Start once congestion is controlled and the person is euvolaemic. Bisoprolol 1.25 mg once daily, target 10 mg daily; carvedilol 3.125 mg twice daily, target 25 mg twice daily (50 mg twice daily over 85 kg); metoprolol succinate 12.5 to 25 mg once daily, target 200 mg.

Mineralocorticoid receptor antagonist. Spironolactone 12.5 to 25 mg orally once daily, target 25 to 50 mg daily, when potassium is under 5.0 mmol/L and eGFR is over 30 mL/min/1.73 m2. Eplerenone 25 mg once daily, target 50 mg daily, if gynaecomastia occurs.

African ancestry. Add hydralazine 37.5 mg with isosorbide dinitrate 20 mg orally three times daily, target double that dose, when symptoms continue despite the four classes.

Special groups. In pregnancy avoid ACE inhibitors, angiotensin receptor blockers, mineralocorticoid antagonists and sacubitril valsartan. In older adults start at half doses. In creatinine clearance under 30 mL/min, limit ramipril to 5 mg daily. In hepatic impairment, carvedilol is not advised.

Monitoring. Daily weights at home. Review at 1 to 2 weeks after starting each drug, checking pressure, heart rate, potassium, creatinine and sodium.

Safe thresholds to proceed. Systolic pressure over 100 mmHg, heart rate over 50 beats a minute, potassium under 5.0 mmol/L and creatinine rise under 30%.

Avoid. NSAIDs, non-dihydropyridine calcium channel blockers, thiazolidinediones, saxagliptin, class I antiarrhythmics and dronedarone.

Stopping. Do not stop a beta blocker suddenly. Reduce the dose for symptomatic bradycardia under 50 beats a minute or hypotension, but keep the drug if possible. Stop an ACE inhibitor for angioedema or potassium over 6.0 mmol/L.

Common errors. Starting a beta blocker in decompensated congestion, stopping renin blockade for a small creatinine rise, and using NSAIDs for pain.

Referral and escalation. Refer for ejection fraction of 35% or under despite 3 months of treatment, ventricular arrhythmia, advanced symptoms, valve disease or suspected peripartum cardiomyopathy.