Download American Heart Association Target Drug Therapy Guidelines for

American Heart Association Target Drug Therapy Guidelines for Heart Failure
Heart Failure (HF) : Heart failure is a complex clinical syndrome that can result from any
structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject
blood.
The following guidelines are from the American Heart Association’s 2009 Updated Guidelines.
The Staging, Level of Evidence criteria and the complete set of guidelines can be found at
http://circ.ahajournals.org/cgi/reprint/119/14/e391.
Drug Therapy for Patients with Current or Prior Symptoms of HF and Low LVEF (Stage C):
Class I: (Level of Evidence)
a. It is recommended that diuretics and salt restriction should be used in patients with
fluid retention. (C)
b. One of the three recommended beta-blocker therapies should be used unless
contraindicated. The recommended beta-blockers are: bisoprolol, carvedilol, or
sustained release metoprolol succinate. (A)
c. Angiotensin II receptor blockers are recommended for patients that are ACEI
intolerant. (A)
d. NSAIDS, most antiarrhythmic drugs and most calcium channel blockers should be
avoided in these patients due to their potential to adversely affect the clinical status of
the patient. (Vasoselective calcium channel blockers are an exception and may be
used.) (B)
e. Addition of an aldosterone antagonist is recommended in these patients with
moderately to severe symptoms of HF who can be carefully monitored for preserved
renal function and normal potassium concentration. Risks may outweigh benefits but
patient should be consistently monitored. (Exact numbers in guidelines pg 22) (B)
f. The combination of hydralazine and nitrates is recommended to improve the
outcomes for African- American patients with moderate-severe symptoms on optimal
therapy with ACEIs, beta-blockers, and diuretics. (B)
Class IIa:
a. It is reasonable to treat patients with atrial fibrillation and HF with a strategy to
maintain sinus rhythm or with a strategy to control ventricular rate alone. (A)
b. Angiotensin II receptor blockers are a reasonable alternative to an ACEI as first-line
therapy in patients with mild-moderate HF, especially if patient is currently taking
and ARB for another indication. (A)
c. Digitalis can be beneficial in these patients to decrease hospitalizations for HF. (B)
d. The addition of a combination of hydralazine and a nitrate is reasonable for these
patients who are already taking an ACEI and beta-blocker for HF symptoms and have
persistent symptoms. (B)
Class IIb:
a. The combination of hydralazine and a nitrate might be reasonable in patients who
cannot be given an ACEI or ARB due to drug intolerance, hypotension, or renal
insufficiency. (C)
b. The addition of an ARB may be considered in persistently symptomatic patients with
reduced LVEF who are already being treated with conventional therapy. (B)
Class III:
a. Routine combination of an ACEI, ARB, and aldosterone antagonist is not
recommended for these patients. (C)
b. Calcium channel blockers are not indicated as routine treatment for these patients. (A)
c. Hormonal therapies other than to replace deficiencies are not recommended and may
be harmful to these patients. (C)
Table 1.Oral Diuretics Recommended for Use in the Treatment of Chronic Heart Failure
Maximum Total Daily
Duration of
Drug
Initial Daily Dose(s)
Dose
Action
Loop Diuretics
Bumetanide
0.5 to 1.0 mg once or twice
10 mg
4 to 6 hours
Furosemide
20 to 40 mg once or twice
600 mg
6 to 8 hours
Torsemide
10 to 20 mg once
200 mg
12 to 16 hours
Thiazide Diuretics
Chlorothiazide
Chlorthalidone
Hydrochlorothiazide
Indapamide
Metolazone
250 to 500 mg once or twice
12.5 to 25 mg once
25 mg once or twice
2.5 mg once
2.5 mg once
1000 mg
100 mg
200 mg
5 mg
20 mg
6 to 12 hours
24 to 72 hours
6 to 12 hours
36 hours
12 to 24 hours
5 mg once
12.5 to 25 mg once
50 to 75 mg twice
20 mg
50 mg†
200 mg
24 hours
2 to 3 days
7 to 9 hours
Potassium-Sparing
Diuretics*
Amiloride
Spironolactone
Triamterene
Sequential Nephron
Blockade
Metolazone
Hydrochlorothiazide
Chlorothiazide (IV)
2.5 to 10 mg once plus loop diuretic
25 to 100 mg once or twice plus loop
diuretic
500 to 1000 mg once plus loop diuretic
IV indicates intravenous; and mg, milligrams. *Eplerenone, although
also a diuretic, is primarily used in chronic heart failure as a
suppressor of the rennin-angiotensin-aldosterone system
† Higher doses may occasionally be used with close monitoring.
Table 6. Inhibitors of the Renin-Angiotensin-Aldosterone System and
Beta Blockers Commonly Used for the Treatment of Patients With HF
With Low Ejection Fraction
Drug
ACE Inhibitors
Captopril
Enalapril
Fosinopril
Lisinopril
Perindopril
Quinapril
Ramipril
Trandolapril
Initial Daily Dose(s)
Maximum
Doses(s)
6.25 mg 3times
2.5 mg twice
5 to 10 mg once
2.5 to 5 mg once
2 mg once
5 mg twice
1.25 to 2.5 mg once
1 mg once
50 mg 3 times
10 to 20 mg twice
40 mg once
20 to 40 mg once
8 to 16 mg once
20 mg twice
10 mg once
4 mg once
Angiotensin Receptor Blockers
Candesartan
Losartan
Valsartan
4 to 8 mg once
25 to 50 mg once
20 to 40 mg twice
32 mg once
50 to 100 mg once
160 mg twice
Aldosterone Antagonists
Spironolactone
Eplerenone
12.5 to 25 mg once
25 mg once
25 mg once or twice
50 mg once
Table 2. Inhibitors of the Renin-Angiotensin-Aldosterone System and Beta Blockers
Commonly Used for the Treatment of Patients with HF with Low Ejection Fraction.
Table 1.Oral Diuretics Recommended for Use in the Treatment of Chronic Heart Failure
Maximum Total Daily
Duration of
Drug
Initial Daily Dose(s)
Dose
Action
Loop Diuretics
Bumetanide
0.5 to 1.0 mg once or twice
10 mg
4 to 6 hours
Furosemide
20 to 40 mg once or twice
600 mg
6 to 8 hours
Torsemide
10 to 20 mg once
200 mg
12 to 16 hours
Thiazide Diuretics
Chlorothiazide
Chlorthalidone
Hydrochlorothiazide
Indapamide
Metolazone
250 to 500 mg once or twice
12.5 to 25 mg once
25 mg once or twice
2.5 mg once
2.5 mg once
1000 mg
100 mg
200 mg
5 mg
20 mg
6 to 12 hours
24 to 72 hours
6 to 12 hours
36 hours
12 to 24 hours
5 mg once
12.5 to 25 mg once
50 to 75 mg twice
20 mg
50 mg†
200 mg
24 hours
2 to 3 days
7 to 9 hours
Potassium-Sparing
Diuretics*
Amiloride
Spironolactone
Triamterene
Sequential Nephron
Blockade
Metolazone
Hydrochlorothiazide
Chlorothiazide (IV)
2.5 to 10 mg once plus loop diuretic
25 to 100 mg once or twice plus loop
diuretic
500 to 1000 mg once plus loop diuretic
IV indicates intravenous; and mg, milligrams. *Eplerenone, although
also a diuretic, is primarily used in chronic heart failure as a
suppressor of the rennin-angiotensin-aldosterone system
† Higher doses may occasionally be used with close monitoring.
Table 6. Inhibitors of the Renin-Angiotensin-Aldosterone System and
Beta Blockers Commonly Used for the Treatment of Patients With HF
With Low Ejection Fraction
Drug
Initial Daily Dose(s)
Maximum
Doses(s)
ACE Inhibitors
Captopril
6.25 mg 3times
50 mg 3 times
Enalapril
2.5 mg twice
10 to 20 mg twice
Fosinopril Reference:
5 to 10 mg once
40 mg once
Incorporated
Into the ACC/AHA 2005 Guidelines
for mg once
Lisinopril American Heart Association. 2009 Focused
2.5Update
to 5 mg
once
20 to 40
in Adults.
Perindoprilthe Diagnosis and Management of Heart Failure
2 mg
once Circulation 2009;119e391-e479. Retrieved
8 to 16 mg once
Quinapril from http://circ.ahajournals.org/cgi/reprint/119/14/e391
5 mg twice
20 mg twice
Ramipril
1.25 to 2.5 mg once
10 mg once
Trandolapril
1 mg once
4 mg once
Angiotensin Receptor Blockers
Candesartan
4 to 8 mg once
32 mg once