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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)