Download Heart Failure Prescribing Guidelines Approved February 2011

Prescribing Guidelines for the management of heart failure due to left
ventricular systolic dysfunction
Heart failure due to left ventricular systolic dysfunction
First line treatment should include (Use clinical judgement to
determine which drug to start first. Titrate the dose of the first drug
before adding the second drug): ACE inhibitor (e.g.ramipril capsules initially 1.25mg once daily
increase gradually at intervals of 1 – 2 weeks to max 10mg daily if
tolerated (preferably taken in two divided doses))
AND

A beta blocker licensed for use in heart failure (use either
bisoprolol or carvedilol see table below). Switch stable patients who
are already taking a beta blocker for a comorbidity to a beta-blocker
licensed for heart failure.
Bisoprolol
Carvedilol
Dose increased after these minimum time intervals if tolerated (weeks)
0
1
2
3
4
5
6
7
8
9
10
1.25mg 2.5mg 3.75mg 5mg od
7.5mg od
od
od
od
3.125mg bd
6.25mg bd
12.5mg
25mg
50mg bd (max)
bd
bd
11
12
10mg od
(max)
Consider an ARB if true ACE
inhibitor intolerance
(recommended first line
choice = candesartan).
Candesartan has been
shown to have an improved
survival benefit over losartan
when used in heart failure).
Candesartan dose:
4mg once daily increased at
intervals of at least 2 weeks
to target dose of 32mg once
daily or to max tolerated
dose.
---------------------------------Offer rehabilitation and education, and diuretics for
congestion and fluid retention
Specialist input
Specialist input
Consider hydralazine in
combination with nitrate if
intolerant of ACE inhibitors and
ARBs
If symptoms persist despite optimal first line treatment, seek specialist advice
and for second line treatment consider adding
 Spironolactone 25mg daily (preferred option in moderate to severe heart
failure or MI in past month). Closely monitor potassium and creatinine
levels and eGFR
OR
 Candesartan 4mg once daily increased at intervals of at least 2 weeks to
target dose of 32mg once daily or to max tolerated dose (preferred option
in mild to moderate heart failure)
OR
 Hydralazine in combination with nitrate (preferred option in people of
African or Caribbean origin with moderate to severe heart failure)
If symptoms persist consider:
 CRT (cardiac resynchronisation therapy)
 Digoxin (routine monitoring of serum digoxin is not recommended
however a digoxin concentration within 8-12 hours may be useful to
confirm clinical impression of toxicity (although toxicity may occur
even when the concentration is within the ‘therapeutic range’) or
non-adherence.
Jacqui Seaton, Head of Medicines Management (version 2 - February 2011)