Patients who have had HF as defined above for some time are often said to have ‘Chronic Heart Failure’. A treated patient with symptoms and signs that have remained generally unchanged for at least 1 month is said to be ‘Stable chronic heart failure’

Pharmacological

Treatment of Systolic Heart Failure (LVEF< 45–50%)

Goals of treatment

• Prevention of disease leading to cardiac dysfunction and heart failure eg hypertension, coronary artery disease, valve disease etc.

• To achieve maintenance or improvement in quality of life and improve survival

  
  

Approach combination therapy

Diuretics

Loop diuretic

Furosemide 40–80mg (PO) twice a day orally

OR

Torsemide 5–20mg (PO) orally

AND

Mineralocorticoid (Aldosterone) Receptor Antagonists:

Spironolactone 25–50mg ounce a day orally

OR

Eplerenone 25–50mg ounce a day orally

Thiazide

• Hydrochlorthiazide 12.5–25mg (PO) once a day

OR

Metolazone 0.1–10mg day

Angiotensin Receptor Inhibitors ACEI or Angiotensin Receptor Blockers (ARB)

Captopril 6.25–25mg three times a day orally

OR

Enalapril 5–20mg twice a day orally.

OR

Perindopril 8mg/daily orally

Angiotensin Receptor Blocker–ARB (*Don’t combine with ACEI contraindicated, Indicated in patient sensitive to ACEIs)

• Losartan 50mg/daily

OR

• Candesartan 4–16mg ounce a day orally.

Beta blocker (Carvedilol–improve Morbidity & Mortality in CHF).

• Carvedilolol 6.25–25mg twice a day especially in heart failure with reduced systolic function

Note: Beta Blockers is contraindication to patients with Bronchial Asthma or Severe Pulmonary Disease Symptomatic bradycardia or hypotension

Add on therapy in patient in NYHA class III/IV.

Vasodilator agents: The combination of hydralazine/nitrate

Isosorbide mononitrate 10–20mg orally 12 hourly

OR

Hydralazine 25 mg 6–8 hourly. Maximum dose: 200 mg/day

Cardiac Glycosides–Digoxin, give with caution! has narrow therapeutic index see below under section of Cardiac Glycosides C: Digoxin 0.125mg–0.25mg once a day orally

Note: Patients at high risk of digoxin toxicity are: Elderly, patients with poor renal function, hypokalaemia and low body weight Consider Anti–thrombotic agents–Heparin &/or warfarin under special indications see below: Congestive Heart Failure with atrial fibrillation, previous thromboembolic events or a mobile LV thrombus Heparin for DVT prophylaxis for patients admitted to hospital, unless contraindicated

Anti–thrombotic agents.

• Heparin &/or warfarin – firmly indicated on congestive heart hailure with atrial fibrillation, previous thromboembolic events or a mobile LV thrombus Heparin for DVT prophylaxis for patients admitted to hospital, unless contraindicated:

• Heparin 5000 units (SC) 8 hourly

  
  

OR

Warfarin oral 5 mg daily. Monitor INR to therapeutic range, i.e. between 2.0–2.5 Thiamine Supplement: Consider in all unexplained heart failure

Referral

Ideally all patients with CHF should be managed in dedicated HF clinics/units with devoted HF expert staffs (nurses & doctors).

The following category of patients should be referred for specialized care

• Severe HF class III/IV

• HF of unknown origin

  
  

  Relative contraindication:

  • Asymptomatic bradycardia and/or low blood pressure

  • Intolerance to low doses

  • Previous use of ß –blockers and discontinuation because of symptoms

  • Bronchial asthma or severe pulmonary disease

Non pharmacological

Patient and family education

• Explain what Heart Failure (HF) is and why symptoms occur, cause of HF, how to recognize symptoms and what to do when they occur, daily self-weighing and what to do in case of weight gain

• Rationale of treatment, importance of adhering to drug & non-drug prescription

• Refrain from smoking

• Prognosis–explain morbidity and mortality

• Drug counseling–Effects, doses and times of administration, side effects and adverse effects

• Dietary and social habit

• Control sodium intake when necessary, avoid excessive fluid intake in severe HF Limit fluid intake to 1–1.5 L/day if fluid overloaded despite diuretic therapy

• Avoid excessive alcohol intake

• Regular exercise within limits of symptoms.

• Sexuality counselling regarding the risk of pregnancy and the use of oral contraceptives and phosphodiesterase-5 inhibitors are not recommended in advanced HF, if used nitrates should be avoided < 24–48hours of nitrate intakes

Medicines to avoid or to be used with caution

NSAIDs & Coxibs

• Class I anti–arrhythmic

• Calcium antagonists

• Lithium

• Tricyclic antidepressants

• Corticosteroids