Heart Failure Treatment Algorithm

Diagnosis and Classification Systolic (HFrEF) –vs- Diastolic (HFpEF)

CLASSIFICATION EJECTION FRACTION DESCRIPTION
I. Heart Failure with Reduced Ejection Fraction (HFrEF) ≤40% Also referred to as systolic HF

II. Heart Failure with Preserved Ejection Fraction (HFpEF) ≥50% Also referred to as diastolic HF

Stages in the Development of HF and Recommended Therapy by Stage

AT RISK FOR HEART FAILURE HEART FAILURE
Stage A Stage B Stage C Stage D
At high risk for HF but Structural heart disease Structural heart disease with Refractory HF
without structural heart but without signs or prior or current symptoms
disease or symptoms of HF symptoms of HF of HF

Etiologies Etiologies E.G., PATIENTS WITH E.G., PATIENTS WITH

• Known structural heart disease and • Marked HF symptoms at rest
E.G., PATIENTS WITH E.G., PATIENTS WITH
• HF signs and symptoms • Recurrent hospitalizations
• HTN • Previous MI Refractory
Structural Development despite maximal medical
• Atherosclerotic disease • LV remodeling including symptoms
heart of symptoms therapy
• DM LVH and low EF of HF at rest,
disease of HF HFpEF HFrEF
• Obesity • Asymptomatic valvular despite GDMT
• Metabolic syndrome disease
or Therapy Therapy Therapy

PATIENTS • Cardiology consult and • Cardiology consult and GOALS

• Using cardiotoxins co-management with PCP co-management with PCP • Control symptoms
• With family history of • Improve quality of life
GOALS GOALS
cardiomyopathy • Reduce hospital
• Control symptoms • Control symptoms
readmissions
• Improve quality of life • Patient education
• Establish patient’s
• Prevent hospitalization • Prevent hospitalization
end-of-life goals
• Prevent mortality • Prevent mortality
Therapy Therapy OPTIONS
STRATEGIES DRUGS FOR ROUTINE USE
GOALS • Cardiology consult • Heart transplant/LVAD
• Identification of • ACEI or ARB
• Heart healthy lifestyle • Chronic inotropes
GOALS comorbidities • Beta blockers
• Prevent vascular, coronary • Experimental surgery
• Prevent HF symptoms • Diuretics for fluid retention
disease TREATMENT or drugs
• Prevent further cardiac • Aldosterone antagonists
• Prevent LV structural • Diuresis to relieve • Palliative care and hospice
remodeling symptoms of congestion DRUGS FOR USE IN
abnormalities • ICD deactivation
DRUGS • Follow guideline driven SELECTED PATIENTS
DRUGS indications for co- • Hydralazine/isosorbide
• ACEI or ARB as appropriate
• ACEI or ARB in appropriate morbidities, e.g., HTN, AF, dinitrate
• Beta blockers as appropriate
patients for vascular disease CAD, DM • Digoxin
or DM IN SELECTED PATIENTS
• Revascularization or valvular IN SELECTED PATIENTS
• Statins as appropriate • ICD
surgery as appropriate • CRT
• Revascularization or valvular
surgery as appropriate • ICD
• Revasculatizaion or valvular
surgery as appropriate
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 Causes of Elevated BNP

CAUSES FOR ELEVATED NATRIURETIC PEPTIDE LEVELS

CARDIAC NONCARDIAC
• Heart Failure, including RV syndromes • Advancing age
• Acute coronary syndrome • Anemia
• Heart muscle disease, including LVH • Renal failure
• Valvular heart disease • Pulmonary causes: obstructive sleep apnea,
• Pericardial disease severe pneumonia, pulmonary hypertension, PE
• Atrial fibrillation • Critical illness
• Myocarditis • Bacterial sepsis
• Cardiac surgery • Severe burns
• Cardioversion • Toxic-metabolic insults, including cancer
chemotherapy and envenomation

Note: BNP and Pro-BNP are not interchangeable and the results cannot be directly compared.

BNP values:
• < 100 pg/mL - excludes the diagnosis of heart failure
• 101-400 pg/mL - unclear, poor-sensitivity and sensitivity for CHF diagnosis
• > 400 pg/mL- likely to be heart failure

Pro-BNP values: (< 300 pg/mL has a 98% negative predictive value for CHF for all age groups.
However, the optimal value for diagnosing CHF with pro-BNP increases with age)
• < 50 yo - proBNP > 450 pg/mL likely to be HF
• 50-75 yo - proBNP > 900 pg/mL likely to be HF
• > 75 yo - proBNP > 1800 pg/mL likely to be HF

Work Up

RECOMMENDATIONS FOR NON-INVASIVE IMAGING

• Chest x-ray, EKG

• A 2-dimensional echocardiogram with Doppler

• Repeat measurement of EF is useful in patients with HF who have had a significant change in
clinical status or received treatment that might affect cardiac function or for consideration
of device therapy.

• If CAD suspected, evaluation for ischemia should be performed.

• Routine repeat measurement of LV function assessment should not be performed.

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 Treatment and Management

SELECTED HEART FAILURE MEDICATIONS

FIRST LINE

Drug Starting Dose for HF Target Dose for HF ~Cost (30 days) Comments

ACEI’s

Lisinopril 2.5 to 5 mg once daily 20 to 40 mg once daily $5 • Use for patients with left ventricular dysfunction unless contraindicated
• May increase dose after one to two weeks.
Enalapril 2.5 mg twice daily 10 mg twice daily $10 • Encourage patients with mild cough to remain on ACEI. If patient cannot tolerate an ACEI due to
cough, substitute ARB.
• Check K+, SCr, and BP within one week of initiation or dosage increase in the elderly, and within one
Ramipril 1.25 to 2.5 mg once daily 5 mg twice daily or 10 mg $10 to two weeks of initiation or dose increase in others. Recheck at regular intervals. SCr increases up to
once daily 30% that stabilize within 2-3 weeks are acceptable. Discontinue if SCr increases more than 1 mg/dL,
or potassium is >5.5 mEq (mmol)/L. If stable, recheck SCr and K+ once or twice yearly, or if patient
condition or meds change.

Beta Blockers

Carvedilol 3.125 mg twice daily 25 mg twice daily $10 • Can start beta-blocker before ACEI is optimized.
• Monitor vitals closely during uptitration. Do not increase dose until any adverse effects
have resolved.
Metoprolol succinate 12.5 to 25 mg once daily 200 mg once daily $15 • If hypotension occurs, separate beta-blocker from other hypotensive agents (e.g., ACEI), or decrease
extended-release diuretic dose.
• For symptoms of severe fatigue, consider other causes such as overdiuresis, sleep apnea,
Bisoprolol 1.25 mg once daily 10 mg once daily $10 or depression.
• Continue beta-blocker even if it does not seem to improve heart failure symptoms.

Aldosterone
Antagonists

Spironolactone 12.5 to 25 mg once daily 25 mg once or twice daily $10 • Use for patients with Class II to IV HF and LVEF 35% or less, unless contraindicated,
(12.5 mg once daily or (12.5 to 25 mg once daily if to reduce morbidity and mortality.
every other day if eGFR eGFR 30-49 mL/min/1.73 m2) • Use for post-MI patients with LVEF 40% or less with symptoms or a history of diabetes,
30-49 mL/min/1.73 m2) unless contraindicated, to reduce morbidity and mortality.
• Do not start if baseline creatinine is over 2.5 mg/dL (221 umol/L) in men or over
Eplerenone 25 mg once daily (every Titrate to 50 mg once daily 2 mg/dL (176.8 umol/L) in women, or eGFR is 30 mL/min/1.73 m2 or lower, or potassium is 5 mEq
other day if eGFR 30-49 mL/ within 4 weeks, as tolerated $80 mmol/L or higher.
min/1.73m2) • Use as an add-on to ACEI (or ARB) plus beta-blocker.
• Discontinue or reduce dose of potassium supplements.
• Counsel patients to avoid NSAIDs and high-potassium foods.
• Check potassium and renal function at regular intervals and when clinically indicated (e.g., ACEI or
ARB initiation or dosage increase, renal function insult, etc).
• Discontinue if hyperkalemia.
• Spironolactone causes more gynecomastia than Eplerenone.

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 Treatment and Management

SELECTED HEART FAILURE MEDICATIONS

FIRST LINE

Drug Starting Dose for HF Target Dose for HF ~Cost (30 days) Comments

Diuretics

Furosemide 20 to 40 mg once or twice daily Max total daily dose 600 mg $5 • Only use for patients with symptoms of fluid retention, to improve symptoms and exercise tolerance,
and to manage beta-blocker associated fluid retention.
Bumetanide 0.5 to 1 mg once or twice daily Max total daily dose 10 mg $15 • Loops preferred, but thiazides can be considered for patients with hypertension and
mild fluid retention.
Torsemide 10 to 20 mg once daily Max total daily dose 200 mg $15 • Adjust dose to attain and maintain target (dry) weight.

Metolazone 2.5 mg once daily Max total daily dose 20 mg $30 • Use metolazone in combination with loop diuretics for refractory patients
• Metolazone dose and dosing frequency may be adjusted based on patient-specific diuretic needs
(eg, administration every other day or weekly).
• Metolazone common dose is 2.5-5.0 mg once or twice daily.

SECOND LINE

ARB’s

Valsartan 20 to 40 mg once daily 160 mg twice daily $30 • Use for patients with ACEI intolerance, or already taking an ARB for another indication
(e.g., hypertension), as an ACEI alternative if necessary.
Candesartan 4 to 8 mg once daily 32 mg once daily $60 • Use for patients with persistent symptoms despite ACEI and beta-blocker, in whom an aldosterone
antagonist cannot be used (i.e., add ARB to ACEI plus beta-blocker).
• Do not combine with ACEI plus aldosterone antagonist.
• In general, titrate by doubling the dose, as tolerated.
• Cautions and monitoring as per ACEIs, above.

ARNI

Sacubitril/valsartan 49/51 mg twice daily 97/103 mg twice daily $400 • Reserve to Cardiology.
(Entresto) • Consider in patients with persistent symptoms despite being at target doses with first-line agents,
especially after a recent HF hospitalization.
• Do not combine with an ACEI or another ARB.
• Do not start if systolic BP <100 mmHg, hyperkalemia, or history of angioedema.
• Monitor for hypotension.
• Start with 24/26 mg in patients who cannot tolerate high doses of ACEI/ARB when being converted.

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 Treatment and Management

SELECTED HEART FAILURE MEDICATIONS

THIRD LINE

Drug Starting Dose for HF Target Dose for HF ~Cost (30 days) Comments

Vasodilators

Hydralazine 25 to 50 mg three times daily 75 mg three times daily $15 • Titrate slowly to improve tolerability.
• Principal adverse effects: headache, dizziness, gastrointestinal side effects.
Isosorbide Dinitrate 20 to 30 mg three times daily 40 mg three times daily $30 • Isosorbide Dinitrate or Mononitrate is acceptable.
• Use hydralazine with a beta blocker unless contraindicated.
Isosorbide Mononitrate 60 to 90 mg once daily 120 mg once daily $20 • Isosorbide/Hydralazine is first line in African Americans.

Isosorbide Dinitrate 20/37.5 mg three times daily 40/75 mg three times daily $200
20 mg/Hydralazine
37.5 mg (BiDil)

FOURTH LINE

Cardiovascular Agent,
Miscellaneous

Digoxin 0.125 mg once daily N/A $15 • Use for patients with LVEF 40% or less, with persistent symptoms despite optimized treatments
above, to decrease HF hospitalization, unless contraindicated. Used as add-on to the
optimized regimen.
• Use for patients with atrial fibrillation and poor rate control despite beta-blocker.
• No loading dose needed for HF.

Ivabradine (Corlanor) N/A N/A $400 • Reserve to Cardiology

• Use for symptomatic patients with LVEF of 35% or lower, in sinus rhythm with resting heart rate of
70 beats per minute or greater despite optimized beta-blocker, ACEI or ARB, and
aldosterone antagonist.
• Use for patients who cannot tolerate target doses of beta-blockers (as an addition to the
beta-blocker) or have a contraindication to beta-blockers.
• Oral: Initial: 5 mg twice daily or 2.5 mg twice daily in patients with a history of conduction defects.

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 Treatment and Management

MEDICATIONS THAT MAY WORSEN OR CAUSE HEART FAILURE

Medications Cause Myocardial Exacerbate Underlying

*Not an all-inclusive list Toxicity Dysfunction

Non-Dihydropyridine Calcium Channel Blockers X

NSAIDs and Selective Cox-2 Inhibitors X

Anthracyclines X X

Antiarrythmics: Flecainide , Disopyramide, Sotalol, Dronedarone X

Select DPP4-Inhibitors: Saxagliptin, Sitagliptin X

Thiazolidinediones (‘Glitazones’) X

TNF-alpha Inhibitors X X

Select Targeted Therapies: Trastuzumab, Bevacizumab X X

Citalopram X

Epoprostenol and Bosentan X

Cilostazol X

Anagrelide X

Pramipexole X

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 Treatment and Management

INDICATIONS FOR DEVICE THERAPY

CLASS I
• EF < 35% and Class II or worse HF
• EF < 30% due to MI regardless of functional class
• Reevaluated at least 40 days after revascularization

CLASS IIb
• EF < 35% without symptoms

CLASS III
• Do not implant a device if they are not likely to survivie a year with a reasonable
quality of life

CRT Device Therapy

• Consider resynchronization therapy in patients with an EF<35% and left bundle
branch block.

Palliative Care
• Consider palliative care consult in patients with multiple co-morbidites

INDICATIONS FOR CARDIAC REHAB & EXERCISE THERAPY

Class I
Exercise training (or regular physical activity) is recommended as safe
and effective for patients with HF who are able to participate to improve
functional status.

Class IIa
Cardiac rehabilitation can be useful in clinically stable patients with HF to
improve functional capacity, exercise, duration, quality of life, and mortality.

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