Drugs used in heart failure management
1.Diuretics; loop diuretics routinely used to relieve symptoms e.g. furosemide 40 mg -24h PO; increase the dose as necessary .SE: hypokaleamia, renal impairment. Monitor U &E and add K+ sparing diuretic if K IS less than 3.2mmol-L,concurrent digoxin therapy ( decreased k+ increase risk of digoxin toxicity),or pre-existing k+-loosing conditions. If refractory edema, consider adding a thiazide e.g. metolazone 5-20mg per 24h PO
2.Digoxin: improves symptoms even in those with sinus rhythm .use it if diuretics, ACE –I and B- blocker do not control symptoms or in patient AF.dose; 0.0125-0.25mg-24h PO. Monitor U&E, maintain k + at 4-5 mmol-L.
3.ACE-inhbitor: consider in all patient with ventricular systolic dysfunctions. It improves symptoms and prolongs life. If cough is a problem an ARBs may be substituted.
4.B-blockers: eg carvedilol, recent randomized trials show that B-blocker decrease mortality in heart failure. Should be initiated after diuretic andACE-i.use with caution; start low and go slow.
5.Vasodilators; the combination of hydralazine (SE; drug induced lupus) and isosorbide dinitrate should be used in combination in people intolerant of an ACE-I or ARBs as it reduces mortality.
6.Hydralazine has one main advantage over ACE inhibitors in that it is safe in pregnancy. It also is not known to worsen renal function in patients with heart failure who have reduced renal function and is not associated with the risk of hyperkalemia.
7.Spironolactone: the rales trial showed that spironolactone (25mg-24h PO) decrease mortality by 30%when added to conventional therapy. It should be initiated in patients who remain symptomatic despite optimal therapy as listed above.