Heart Failure Medicine Titration

Heart failure medicine titration raises each drug stepwise to the target dose proven to reduce death and admission, or to the highest dose the person tolerates. Doses are increased every 2 to 4 weeks, one drug at a time, with the low-dose version of all four classes preferred over a high dose of one. A lower dose is still beneficial, so never stop a drug for failure to reach target.

Order. Change one drug at a time, review at 1 to 2 weeks, and alternate between classes when pressure is limiting.

Congestion first. Reduce diuretics if the person is euvolaemic and pressure is low, before reducing prognostic drugs.

Doses to hold. Do not increase when systolic pressure is under 100 mmHg or the person is symptomatic, heart rate is under 50 beats a minute, potassium is over 5.0 mmol/L, or the person is congested or unwell.

Special groups. Older adults may reach lower doses. In creatinine clearance under 30 mL/min, cap ramipril at 5 mg daily and be cautious with spironolactone. In African ancestry, add hydralazine with isosorbide dinitrate if target doses do not control symptoms. In pregnancy, use none of the ACE inhibitors, angiotensin receptor blockers or mineralocorticoid antagonists.

Monitoring. Check pressure, heart rate, weight, potassium, sodium and creatinine 1 to 2 weeks after each step. Repeat the echocardiogram after 3 months on optimum treatment.

Laboratory limits. A creatinine rise up to 30% is acceptable, and up to 50% over baseline (or 266 micromol/L) may be accepted briefly. Stop the ACE inhibitor or mineralocorticoid antagonist if the rise exceeds 100% or creatinine reaches 310 micromol/L. Halve spironolactone for potassium of 5.5 to 5.9 mmol/L, and stop it at 6.0 mmol/L or over.

Hypotension. Separate dosing times, reduce the diuretic if euvolaemic, and review other vasodilators before cutting a prognostic drug.

Stopping. Reduce the beta blocker by half for worsening heart failure, bradycardia under 50 beats a minute or symptomatic hypotension, and restart once stable. Do not stop it suddenly.

Common errors. Rapid doubling, stopping at the first dose limit, and leaving a person on starter doses.

Referral and escalation. Refer when target doses cannot be reached, for ejection fraction of 35% or under after 3 months, or for worsening symptoms, arrhythmia or kidney function.