Heart failure
Test
SIGN 147 Heart Failure NICE CG106 Chronic Heart Failure Adults
1.25mg daily for 1 week, increased, if well tolerated, to 2.5mg daily for 1 week, then 3.75mg daily for 1 week, then 5mg daily for 4 weeks, then 7.5mg daily for 4 weeks, then 10mg daily maintenance: hypertension and angina, usually 5-10mg once daily; max 10mg daily.
1.25mg daily for 1 week, increased, if well tolerated, to 2.5mg daily for 1 week, then 3.75mg daily for 1 week, then 5mg daily for 4 weeks, then 7.5mg daily for 4 weeks, then 10mg daily maintenance: hypertension and angina, usually 5-10mg once daily; max 10mg daily.
1.25mg daily for 1 week, increased, if well tolerated, to 2.5mg daily for 1 week, then 3.75mg daily for 1 week, then 5mg daily for 4 weeks, then 7.5mg daily for 4 weeks, then 10mg daily maintenance: hypertension and angina, usually 5-10mg once daily; max 10mg daily.
1.25mg daily for 1 week, increased, if well tolerated, to 2.5mg daily for 1 week, then 3.75mg daily for 1 week, then 5mg daily for 4 weeks, then 7.5mg daily for 4 weeks, then 10mg daily maintenance: hypertension and angina, usually 5-10mg once daily; max 10mg daily.
1.25mg daily for 1 week, increased, if well tolerated, to 2.5mg daily for 1 week, then 3.75mg daily for 1 week, then 5mg daily for 4 weeks, then 7.5mg daily for 4 weeks, then 10mg daily maintenance: hypertension and angina, usually 5-10mg once daily; max 10mg daily.
1.25mg daily for 1 week, increased, if well tolerated, to 2.5mg daily for 1 week, then 3.75mg daily for 1 week, then 5mg daily for 4 weeks, then 7.5mg daily for 4 weeks, then 10mg daily maintenance: hypertension and angina, usually 5-10mg once daily; max 10mg daily.
1.25-10mg once daily. In symptomatic heart failure the target dose, if tolerated is 10mg daily which may be taken in 2 divided doses.
1.25-10mg once daily. In symptomatic heart failure the target dose, if tolerated is 10mg daily which may be taken in 2 divided doses.
1.25-10mg once daily. In symptomatic heart failure the target dose, if tolerated is 10mg daily which may be taken in 2 divided doses.
1.25-10mg once daily. In symptomatic heart failure the target dose, if tolerated is 10mg daily which may be taken in 2 divided doses.
3.125mg twice daily, increased at intervals of at least 2 weeks, then 6.25mg twice daily, then 12.5mg twice daily then 25mg twice daily, to the highest tolerated dose; max 25mg twice daily in patients with severe heart failure or body-weight less than 85mg or max. 50mg twice daily in patients over 85kg.
3.125mg twice daily, increased at intervals of at least 2 weeks, then 6.25mg twice daily, then 12.5mg twice daily then 25mg twice daily, to the highest tolerated dose; max 25mg twice daily in patients with severe heart failure or body-weight less than 85mg or max. 50mg twice daily in patients over 85kg.
3.125mg twice daily, increased at intervals of at least 2 weeks, then 6.25mg twice daily, then 12.5mg twice daily then 25mg twice daily, to the highest tolerated dose; max 25mg twice daily in patients with severe heart failure or body-weight less than 85mg or max. 50mg twice daily in patients over 85kg.
3.125mg twice daily, increased at intervals of at least 2 weeks, then 6.25mg twice daily, then 12.5mg twice daily then 25mg twice daily, to the highest tolerated dose; max 25mg twice daily in patients with severe heart failure or body-weight less than 85mg or max. 50mg twice daily in patients over 85kg.
1.25-10mg once daily. In symptomatic heart failure the target dose, if tolerated is 10mg daily which may be taken in 2 divided doses.
1.25-10mg once daily. In symptomatic heart failure the target dose, if tolerated is 10mg daily which may be taken in 2 divided doses.
1.25-10mg once daily. In symptomatic heart failure the target dose, if tolerated is 10mg daily which may be taken in 2 divided doses.
1.25-10mg once daily. In symptomatic heart failure the target dose, if tolerated is 10mg daily which may be taken in 2 divided doses.
In patients who are intolerant of ACE inhibitors, an angiotensin-II receptor antagonist may be considered as an alternative to an ACEi in combination with bisoprolol or carvedilol.
Initially 4mg once daily, increased at intervals of at least 2 weeks to 'target' dose of 32mg once daily or to maximum tolerated dose; maximum 32mg per day.
Initially 4mg once daily, increased at intervals of at least 2 weeks to 'target' dose of 32mg once daily or to maximum tolerated dose; maximum 32mg per day.
Initially 4mg once daily, increased at intervals of at least 2 weeks to 'target' dose of 32mg once daily or to maximum tolerated dose; maximum 32mg per day.
Initially 4mg once daily, increased at intervals of at least 2 weeks to 'target' dose of 32mg once daily or to maximum tolerated dose; maximum 32mg per day.
Initially 4mg once daily, increased at intervals of at least 2 weeks to 'target' dose of 32mg once daily or to maximum tolerated dose; maximum 32mg per day.
Initially 12.5mg once daily, increased if tolerated to up to 150mg once daily, doses to be increased at weekly intervals.
Initially 12.5mg once daily, increased if tolerated to up to 150mg once daily, doses to be increased at weekly intervals.
Initially 12.5mg once daily, increased if tolerated to up to 150mg once daily, doses to be increased at weekly intervals.
Prescribing Notes:
- Bisoprolol is first choice beta-blocker for stable, chronic heart failure initiated under specialist supervision. Carvedilol is second-line for patients intolerant of bisoprolol in heart failure.
- Beta-blockers may cause bronchospasm; avoid in patients suffering asthma. If a beta-blocker is required a cardioselective beta-blocker should be selected, initiated at a low dose and the patient closely monitored.
- For heart failure the dose of the ACE inhibitor should be titrated to a ‘target’ dose (or to the maximum tolerated dose if lower). See BNF.
- Angiotensin-II receptor antagonists should be reserved for patients who develop a persistent cough with ACE inhibitors.
- Urea and electrolytes should be checked within 2 weeks of commencing ACEi/ ARII therapy and after any change in dose.
- TEST
History Notes
28/02/2023
Updates to prescribing information ERWG Jan 2023.
28/11/2022
Losartan dose edited to reflect BNF, ERFC Sept 22.
16/02/2022
East Region Formulary content agreed.
Initially 40mg daily, then adjusted according to response.
Initially 40mg daily, then adjusted according to response.
Slow intravenous injection: initially 20-50mg. Furosemide may be given by intravenous infusion at a rate not exceeding 4mg/minute.
Slow intravenous injection: initially 20-50mg. Furosemide may be given by intravenous infusion at a rate not exceeding 4mg/minute.
Slow intravenous injection: initially 20-50mg. Furosemide may be given by intravenous infusion at a rate not exceeding 4mg/minute.
Bumetanide may be an option in those patients that are not responding to furosemide (1mg bumetanide is equivalent to 40mg furosemide).
Initially 1mg daily then adjusted according to response.
Initially 1mg daily then adjusted according to response.
Prescribing Notes:
- Furosemide produces a dose-dependent diuresis within 1 hour if given orally or 30 minutes if given intravenously; duration of action, 6 hours.
- Thiazide diuretics should only be prescribed with loop diuretics such as furosemide for severe heart failure under hospital supervision; this must be carefully monitored.
History Notes
16/02/2022
East Region Formulary content agreed.
NYHA class III/IV heart failure.
25mg daily; higher doses may be needed in liver failure.
25mg daily; higher doses may be needed in liver failure.
25mg daily; higher doses may be needed in liver failure.
NYHA class II heart failure. Eplerenone may be prescribed for patients who develop gynaecomastia with spironolactone.
Initially 25mg once daily, increased within 4 weeks to 50mg once daily.
Initially 25mg once daily, increased within 4 weeks to 50mg once daily.
See prescribing notes for information on sacubitril/ valsartan.
In patients not currently taking an ACE inhibitor or angiotensin II receptor antagonist, or stabilised on low doses of either of these agents, initially 26/24 mg twice daily for 3-4 weeks, increased if tolerated to 51/49 mg twice daily for 3-4 weeks, then increased if tolerated to 103/97 mg twice daily. In patients currently stabilised on an ACE inhibitor or angiotensin II receptor antagonist), initially 51/49 mg twice daily for 2-4 weeks, increased if tolerated to 103/97 mg twice daily, consider a starting dose of 26/24 mg if systolic blood pressure less than 110 mmHg.
In patients not currently taking an ACE inhibitor or angiotensin II receptor antagonist, or stabilised on low doses of either of these agents, initially 26/24 mg twice daily for 3-4 weeks, increased if tolerated to 51/49 mg twice daily for 3-4 weeks, then increased if tolerated to 103/97 mg twice daily. In patients currently stabilised on an ACE inhibitor or angiotensin II receptor antagonist), initially 51/49 mg twice daily for 2-4 weeks, increased if tolerated to 103/97 mg twice daily, consider a starting dose of 26/24 mg if systolic blood pressure less than 110 mmHg.
In patients not currently taking an ACE inhibitor or angiotensin II receptor antagonist, or stabilised on low doses of either of these agents, initially 26/24 mg twice daily for 3-4 weeks, increased if tolerated to 51/49 mg twice daily for 3-4 weeks, then increased if tolerated to 103/97 mg twice daily. In patients currently stabilised on an ACE inhibitor or angiotensin II receptor antagonist), initially 51/49 mg twice daily for 2-4 weeks, increased if tolerated to 103/97 mg twice daily, consider a starting dose of 26/24 mg if systolic blood pressure less than 110 mmHg.
Refer to prescribing notes for information on SGLT2 inhibitors.
10mg once daily.
Refer to prescribing notes for information on SGLT2 inhibitors.
10mg once daily
Where heart rate remains ≥75bpm despite optimal therapy or; intolerance or contraindication to beta-blockers.
Initially 5mg twice daily, increased if necessary after 2 weeks to 7.5mg twice daily (if not tolerated reduce dose to 2.5mg twice daily).
Initially 5mg twice daily, increased if necessary after 2 weeks to 7.5mg twice daily (if not tolerated reduce dose to 2.5mg twice daily).
Prescribing Notes:
- Some of these drugs may be given in combination, refer to local and national guidelines on management of heart failure for more information.
Mineralocorticoid receptor antagonists (aldosterone antagonist)
- Spironolactone 25mg daily has been shown to reduce mortality in patients with severe heart failure receiving standard therapy including ACE inhibitors; renal function and electrolytes should be monitored.
- Eplerenone may be prescribed for patients who develop gynaecomastia with spironolactone.
Sacubitril/valsartan
- Sacubitril/valsartan is recommended for specialist initiation for treating adult patients with significant left ventricular systolic dysfunction (at least moderate LVSD or LVEF <40%) who:
- Have been hospitalised due to heart failure within the previous 6 months
- Have ongoing symptoms of heart failure (NHYA class II-IV) despite maximally tolerated doses of ACE inhibitor/angiotensin-II receptor antagonist, beta blocker and aldosterone antagonist
- Sacubitril/valsartan is contraindicated if systolic blood pressure <100mmHg.
- If a patient is already on an ACE inhibitor then it should be stopped for at least 48hours before initiating sacubitril/valsartan to minimise the risk of angioedema.
- No washout period is required for patients already taking an angiotensin-II receptor antagonist.
Sodium-glucose co-transporter 2 (SGLT2) inhibitors
- The SGLT2 inhibitors, dapagliflozin or empagliflozin are recommended for initiation on specialist advice as add-on therapy for the treatment of symptomatic chronic heart failure.
- Dapagliflozin or empagliflozin may be prescribed alongside other standard therapies including ACE inhibitor/ angiotensin II receptor antagonist/ sacubitril-valsartan, beta blocker, aldosterone antagonist or in place of these therapies if they are contraindicated or not tolerated.
- When used in heart failure, the dose of dapagliflozin in patients with or without type 2 diabetes mellitus is 10mg daily. It does not need to be adjusted based on renal function. It is not recommended to initiate treatment if eGFR< 15ml/min/1.73m2.
- When used in heart failure the dose of empagliflozin in patients with or without type 2 diabetes mellitus is empagliflozin 10 mg. Empagliflozin may be initiated or continued down to an eGFR of 20 ml/min/1.73 m2 or CrCl of 20 ml/min.
- Patients on SGLT2 inhibitors should be given advice on genitourinary infections and stopping treatment during acute, dehydrating intercurrent illness (‘Sick day guidance’). Diabetic ketoacidosis is a rare but life-threatening side-effect of SGLT2 inhibitors.
- In patients with type 2 diabetes, other treatments – and sulfonylurea and insulin in particular – may need to be adjusted to minimise risk of hypoglycaemia when starting an SGLT2 inhibitor.
- Dapagliflozin is not recommended for the management of heart failure in patients with type 1 diabetes due to the lack of safety and efficacy data for that population. Diabetes specialist should be contacted for advice if this is being considered.
Ivabradine
- Ivabradine is associated with an increased risk of bradycardia and atrial fibrillation. It should only be used when pre-treatment resting heart rate is above 70bpm in sinus rhythm, and should not be used in conjunction with verapamil or diltiazem. Reduce the dose or discontinue ivabradine if resting HR falls below 50bpm. Avoid ivabradine in patients with a history of AF.
- Ivabradine is also approved for use, on the initiation of a specialist, for chronic heart failure NYHA class II to IV with systolic dysfunction, in patients in sinus rhythm and whose heart rate is ≥75bpm, in combination with standard therapy including beta-blocker therapy or when beta-blocker therapy is contra-indicated or not tolerated.
- Further safety advice on the use of ivabradine was published by the MHRA as a Drug Safety update in December 2014.
History Notes
28/09/2023
Updates to prescribing information, Empagliflozin SMC2523 ERFC June 23, Dapagliflozin SMC2577 Aug 23.
28/02/2023
Addition of empagliflozin SMC2396 and updates to prescribing notes ERWG Jan 2023.
16/02/2022
East Region Formulary content agreed.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
ACE inhibitor – captopril. Urea and electrolytes and renal function should be checked before and within 1 week of commencing therapy and monitored during treatment.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
ACE inhibitor – lisinopril. Urea and electrolytes and renal function should be checked before and within 1 week of commencing therapy and monitored during treatment.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Digoxin – for oral therapy round the dose to the nearest 5micrograms to assist administering the dose.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
Prescribing Notes:
- Medicines included for heart failure in paediatrics are either used individually or in combination(s).
- Furosemide produces a dose-dependent diuresis within 1 hour if given orally or 30 minutes if given intravenously; duration of action, 6 to 8 hours. Half-life is very variable in the neonatal period and may be up to 24hours in preterm infants.
- In an intensive care setting, continuous infusion of furosemide may be given.
- In children no longer in nappies, time doses to minimize social disruption.
- Captopril and lisinopril tablets can be halved and will disperse in water.
- For heart failure the dose of the ACE inhibitor should be titrated to a ‘target’ dose (or to the maximum tolerated dose if lower). See BNFc.
- Regular measurements of plasma digoxin concentrations are not usually required except to confirm toxic or sub-therapeutic levels, or to check compliance.
- Digoxin should be used with particular caution in patients with renal impairment.
- Hypokalaemia predisposes to digoxin toxicity.
- Digoxin levels may be increased by co-prescription of other drugs such as amiodarone, quinidine, quinine, hydroxychloroquine.
- Beta-blockers may cause bronchospasm; they are usually avoided in patients suffering asthma but are sometimes used on specialist advice.
History Notes
19/06/2023
East Region Formulary content agreed - ERFC 07/06/2023.