|
Asymptomatic LV Dysfubction
|
Mild to moderate CHF
|
Moderate to severe CHF
|
| ACE inhibitor |
Digoxin |
Digoxin |
| Beta blocker |
Diuretics |
Diuretics |
| |
ACE inhibitor |
ACE inhibitor |
| |
Beta blocker |
Beta blocker |
| |
Spironolactone |
|
The following figure presents a treatment algorithm
summarizing the recommended use of diuretics, ACE inhibitors,
beta-blockers and digitalis in the management of heart
failure.
Other drugs recommended
for use in selective patients with systolic dysfunction
| A. Anticoagulants |
All patients of heart failure having
atrial fibrillation should be treated with warfarin
[goal, international normalized ratio (INR) 2.0
to 3.0] unless contraindicated |
| B. Angiotensin II receptor antagonists |
- Used in patients who are intolerant
to ACE inhibitors due to angioedema or intractable
cough
- Can be initiated at a dose of 12.5 mg daily titrated
to 25 mg and then 50 mg once daily at weekly intervals
|
| C. Hydralazine and Isosorbide Dinitrate |
- Combined use of hydralazine and
isosorbide dinitrate should be considered as a therapeutic
option in patients intolerant of ACE inhibitors,
particularly in those who cannot take an ACE inhibitor
because of hypotension or renal insufficiency
- Initial dose: hydralazine 10 mg four times a day,
isosorbide dinitrate 10 mg three times a day
Target dose: hydralazine 75 mg four times a day,
isosorbide dinitrate 40 mg three times a day
|
| D. Spironolactone |
- Low-dose spironolactone (12.5 mg
to 25 mg once daily) should be considered for patients
receiving therapy who have severe heart failure
(recent or current NYHA class IV) caused by left
ventricular systolic dysfunction.
- Serum potassium concentration should be monitored
after the first week and at regular intervals thereafter.
Consideration should be given to lowering or eliminating
supplemental potassium |
| F. Antiarrhythmic agents (Class III)
(e.g. Amiodarone) |
Amiodarone is the preferred drug when
antiarrhythmic therapy is indicated in patients
with heart failure for supraventricular tachycardia
not controlled by digoxin or blocker or for patients
with life-threatening ventricular arrhythmia who
are not candidates for implantable cardiac defibrillators
|
Metabolic drugs like trimetazidine and L-carnitine have
shown beneficial effects in dilated and ischaemic LV
dysfunction.
Further reading
1. Consensus Recommendations for the Management
of Chronic Heart Failure. Am J Cardiol 1999; 83 (2A):
1A-38A
2. Diastolic Heart Failure. New Ethicals August 2000:
25-29
3. Understanding the Management of Heart Failure. Pharmacotherapy
2000; 20: 493-494
4. Hormones and Hemodynamics in Heart Failure. New Eng
J Med 1999; 341: 577-585
|
