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
- DIURETIC (urinate off all the excess fluid in a volume-overloaded patient)
- ACE inhibitor or Angiotensin Receptor Blocker (ARB)
- contraindicated if symptomatic hypotension (SBP<90 or MAP<65)
- 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.
- 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.
- Inotropic agent(s)
- Do NOT use CCBs like diltiazem/verapamil – worse outcomes in patients with heart failure.
ACP MKSAP 17: Cardiovascular Medicine, pp. 32-34