Congestive heart failure pharmacotherapy

Jump to navigation Jump to search
Congestive Heart Failure Microchapters


Patient Information


Historical Perspective



Systolic Dysfunction
Diastolic Dysfunction


Differentiating Congestive heart failure from other Diseases

Epidemiology and Demographics

Risk Factors


Natural History, Complications and Prognosis


Clinical Assessment

History and Symptoms

Physical Examination

Laboratory Findings


Chest X Ray

Cardiac MRI


Exercise Stress Test

Myocardial Viability Studies

Cardiac Catheterization

Other Imaging Studies

Other Diagnostic Studies


Invasive Hemodynamic Monitoring

Medical Therapy:

Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF
ACE Inhibitors
Angiotensin receptor blockers
Aldosterone Antagonists
Beta Blockers
Ca Channel Blockers
Positive Inotropics
Angiotensin Receptor-Neprilysin Inhibitor
Antiarrhythmic Drugs
Nutritional Supplements
Hormonal Therapies
Drugs to Avoid
Drug Interactions
Treatment of underlying causes
Associated conditions

Exercise Training

Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Cardiac Surgery
Left Ventricular Assist Devices (LVADs)
Cardiac Transplantation

ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

Congestive heart failure pharmacotherapy On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides


Ongoing Trials at Clinical

US National Guidelines Clearinghouse

NICE Guidance

FDA on Congestive heart failure pharmacotherapy

CDC on Congestive heart failure pharmacotherapy

Congestive heart failure pharmacotherapy in the news

Blogs on Congestive heart failure pharmacotherapy

Directions to Hospitals Treating Congestive heart failure pharmacotherapy

Risk calculators and risk factors for Congestive heart failure pharmacotherapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Seyedmahdi Pahlavani, M.D. [3]


Management of patients with heart failure reduced ejection fraction (HFrEF)

Abbreviations: ACE-I: Angiotensin-converting enzyme inhibitor; ARNI: Angiotensin receptor-neprilysin inhibitor; CRT-D: cardiac resynchronization therapy with defibrillator  ; CRT-P: cardiac resynchronization therapy with pacemaker; ICD: Implantable cardioverter-defibrillator; HFrEF: Heart failure with reduced ejection fractio;

Management of HFrEF
(Class I)
LVEF ≤35% and QRS <130 ms
LVEF >35% or device

therapy not indicated

or inappropriate
Sinus rhythm and LVEF ≤35% and QRS ≥130 ms
ICD implantation
If symptoms persist, consider therapies (class II)
  • QRS ≥150 ms (Class I)
  • QRS 130-149 ms (Class IIa)
    The above table adopted from 2021 ESC Guideline


    Congestive heart failure treatment summary based on 2021 AHA/ACC Guideline


    Pathophysiology Treatment
    Renin-angiotensin-aldosterone system ARNIs/ACEIs/ARBs, aldosterone antagonist
    Sympathetic nervous system Beta-blockers
    Natriuretic and other vasodilator peptides Neprilysin inhibitor (ARNI)
    Sodium-glucose cotransporter-2 SGLT2 inhibitors
    Balanced vasodilation and oxidative stress modulation Hydralazine/Isosorbide dinitrate
    Elevated heart rate Betablocker, Ivabradine
    Guanylyl cyclase Soluble guanylyl cyclase stimulator
    Relief of congestion Diuretic
    Ventricul;ar arrhythmia Implantable cardioverter defibrilator
    Ventricular dyssynchrony due to conduction abnormalities Cardiac resynchronization therapy
    Mitral regurgitation Surgical or percutaneous Mitral repair
    Reduced aerobic capacity Aerobic exercise training
    The above table adopted from 2021 AHA/ACC Guideline

    Treatment Algorithm for Guideline-Directed Medical Therapy Including Novel Therapies

    Heart failure reduced EF, stage C, treatment
    For patients with eGFR≥ 30 mL/min/1.73m² or creatinine≤ 2.5 mg/dL in males or ≤2 mg/dL in females or K≤ 5 mEq/L, NYHA 2-4
    For patients with eGFR criteria, NYHA 2-4
    For patients with persistent volume overload, NYHA 2-4
    For symptomatic black patients despite receiving ARNI, betablocker,aldosterone antagonist, SGLT2 inhibitor, NYHA 3-4
    For patients with resting HR>70/min despite maximum tolerated betablocker dose, sinus rhythm, NYHA 2-3
    Aldosterone antagonist
    SGLT2 inhibitor
    Diuretic agents
    Hydralazine + Isosorbide dinitrate
    The above algorithm adopted from 2021 AHA/ACC Guideline

    Starting in patient if ARNI is not accessible
    Dosage initiation based on indication
    Increasing dose every 2 weeks until achieving target dose or maximum tolerance and monitoring of blood pressure, renal function, potassium after initiation and during titration

    Initiation after 36 hours of discontinuing ACEI, if the patient is on ACEI
    Dosage initiation based on indication
    24/26 mg twice daily if the patient is taking enalapril≤ 10 mg/day or valsartan≤ 160 mg/day
    49/51 mg twice daily if the patient is taking enalapril> 10 mg/day or valsartan > 160 mg/day
    In 2 weeks assessment about tolerance, blood pressure, electrolytes, renal function and dosage titration to target of 97/103 mg twice daily

    Initiation loop diuretic dose based on renal function, previous use of diuretics
    Titration dose until recovery of congestion, reducing dose in concomitant administration of ACEI, ARB, ARNI, monitoring blood pressure, renal function, electrolytes after initiation and during titration dose
    In high dose of loop diuterics (80 mg furosemide twice daily), Considering other type of loop diuretics or adding thiazide to loop diuretic by monitoring of blood pressure, renal function, electrolytes after initiation dose or during titration

    SGLT2 inhibitor
    Dosage initiation based on indication
    Initiation dapaglifelozin in eGFR≥ 30 mL/min/1.73 m², and empagliflozin in eGFR≥ 20 mL/ min/1.73 m²

    Dosage initiation based on indication
    Dosage titration every two weeks until achieving target dose or maximum tolerance, monitoring heart rate , blood pressure after initiation and during titration

    Aldosterone antagonist
    Dosage initiation based on indication
    Increase dose every 2 weeks up to maximum dose or achieving tolerated dose, monitoring electrolytes and renal function at 2-3 days following initiation then 7 days after initiation or titration, then monthly for 3 months and every 3 months afterward, clinical status monitoring

    Hydralazine, isosorbide dinitrate
    Increase dose every 2 weeks until target dose or achieving tolerated dose with monitoring of blood pressure

    Sacubitril/Valsartan Ivabradine SGLT2 Inhibitors
    Contraindications Contraindications Contraindications
    • Renal impairment:
      Mild-to-moderate (eGFR 30-59 mL/ min/1.73 m2): no starting dose adjustment required
    • Severe (eGFR <30 mL/min/ 1.73 m2):
      Reduce starting dose to 24/26 mg twice daily,
      Double the dose every 2–4 weeks to target maintenance dose of 97/103 mg twice daily, as tolerated
    • Hepatic impairment:
      Mild (Child-Pugh A): no starting dose adjustment required
      Moderate (Child-Pugh B):
      Reduce starting dose to 24/26 mg twice daily
      Double the dose every 2–4 weeks to target maintenance dose of 97/103 mg twice daily, as tolerated
    • Renal artery stenosis
    • Systolic blood pressure <100 mm Hg
    • Volume depletion
    Causions Causions

    For prevention of ketoacidosis in patients with diabetes:

    erythema, or swelling in the genital or perineal area, along with fever or malaise

    The above table adopted from 2021 AHA/ACC Guideline[2]

    Given Betablocker by maximum tolerable dose, sinus rhythm on ECG
    Starting dose
    Age ≥ 75 years, 2.5 mg twice daily with food
    Age <75 years, 5 mg twice daily with food
    Evaluation of heart rate in 2-4 weeks
    Heart rate < 50 beats /min or symptoms of bradycardia
    Heart rate 50-60 beats/ min
    Heart rate>60 beats /min
    Reduced dose 2.5 mg twice daily with food, or discontinued if already on 2.5 mg twice daily
    Maintaing current dose with monitoring heart rate
    Increased dose by 2.5 mg twice daily until maximum dose of 7.5 mg twice daily, monitoring heart rate


    1. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland J, Coats A, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam C, Lyon AR, McMurray J, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano G, Ruschitzka F, Kathrine Skibelund A (September 2021). "2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure". Eur Heart J. 42 (36): 3599–3726. doi:10.1093/eurheartj/ehab368. PMID 34447992 Check |pmid= value (help). Vancouver style error: initials (help)
    2. 2.0 2.1 Bozkurt B, Hershberger RE, Butler J, Grady KL, Heidenreich PA, Isler ML, Kirklin JK, Weintraub WS (April 2021). "2021 ACC/AHA Key Data Elements and Definitions for Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Clinical Data Standards for Heart Failure)". Circ Cardiovasc Qual Outcomes. 14 (4): e000102. doi:10.1161/HCQ.0000000000000102. PMC 8059763 Check |pmc= value (help). PMID 33755495 Check |pmid= value (help).

    Template:WikiDoc Sources