Heart Failure with Reduced Ejection Fraction (also known as systolic heart failure) is broken up into two phases of treatment:  the acute (on presentation to the hospital) and chronic (long-term to prevent re-hospitalization).

Acute Exacerbation Treatment
  1. DIURETIC (urinate off all the excess fluid in a volume-overloaded patient)
  2. ACE inhibitor or Angiotensin Receptor Blocker (ARB)
    • contraindicated if symptomatic hypotension (SBP<90 or MAP<65)
  3. After symptoms have improved/resolved, initiate a beta-blocker
    • Metoprolol succinate, carvedilol, bisoprolol all show mortality benefit.
    • A history of COPD is NOT a contraindication to BB therapy.
Long-Term Treatment
  • Chronic therapy is dictates by patient’s FUNCTIONAL status (NY Heart Association Class) and other symptoms of fluid status.
    • I – No limits on physical activity
    • II – Mild limitation of physical activity
    • III – Marked limitation of physical activity
      • IIIA – symptoms with less than ordinary activity
      • IIIB – symptoms with minimal exertion
    • IV – cannot perform physical activity without symptoms.
  • Treatments that reduce mortality and reduce re-hospitalization:
    • ACE inhibitors – can also improve LVEF, ok to use with Creatinine < 3.0
    • Beta-blockers – block chronic neurohormonal activation
    • Aldosterone antagonist (aldactone) – give for NYHA class II, III, and IV
      • Ok to use with Creatinine < 2.5 in men and < 2.0 in women.
    • For black patients with class III/IV – Hydralazine-isosorbide dinitrate
      • Use as supplemental therapy (not replacing other agents).
    • Combination of ACEi and Beta-blocker is best (rather than either alone).
  • Medications to improve symptoms, only:
    • Digoxin – better quality of life and improved exercise tolerance.  Careful with kidney failure patients.
    • Diuretics
    • Vasodilators
    • Inotropic agent(s)
  • Do NOT use CCBs like diltiazem/verapamil – worse outcomes in patients with heart failure.

Bibliography
ACP MKSAP 17:  Cardiovascular Medicine, pp. 32-34

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