MRA (spironolactone or eplerenone) 

A prescription for spironolactone may highlight a HF patient especially if prescribed in combination with the other HF medicines however it has other indications (e.g., hypertension, management of ascites in liver disease). Eplerenone is only licensed for HF. Although these medicines are classed as diuretics in Heart Failure with Reduced Ejection Fraction (HFrEF) they have been shown to improve mortality and hence are mainly prescribed for their prognostic benefit rather than their diuretic effects.

Sacubitril + valsartan (Entresto) 

Entresto is only licensed for the treatment of heart failure. It is approved by NICE for specialist initiation/recommendation so depending on your local arrangements you may find that the prescription has been provided by the specialist team or from the GP on specialist advice. Importantly sacubitril + valsartan is prescribed instead of an ACEi (risk of angio-oedema if given with an ACEi) or any other ARB (Entresto contains the ARB valsartan) so it is important that the patient knows:

• To stop any ACEi at least 36 hours before commencing sacubitril + valsartan
• That the ACEi is permanently discontinued
• To stop any ARB before commencing sacubitril + valsartan. A wash out period is not needed. The first dose of sacubitril + valsartan can be taken when the next dose of ARB had been due.

SGLT2i (dapagliflozin, empagliflozin) 

In the management of type 2 diabetes, the SGLT2i medicines have been available for several years. Recent trials with dapagliflozin and empagliflozin have shown that they reduce both symptoms and mortality in patients with HF in patients with or without type 2 diabetes and has rapidly expanded the number of patients eligible for treatment. This can cause some confusion – do not assume that the patient has diabetes. 

Most HF medicines will need to be taken long-term, with the exception of diuretics, which may be reduced or stopped altogether depending on fluid retention or, conversely, may need a dose increase or to be re-introduced if congestion increases.