Managing heart failure
Managing heart failure
The more common treatments used in the management of HF are outlined in Table 1. Recent changes in the prescribing of treatment for heart failure include the increased use of sacubitril + valsartan and SGLT2i.
It can be difficult to spot the ‘heart failure patient’ as many of the medicines prescribed for HF are used more widely for cardiac (e.g., hypertension, angina) and non-cardiac (type 2 diabetes) conditions. A typical community pharmacy will have around 100 patients with HF and each year will have an additional 14 newly diagnosed patients.
Diuretics
Peripheral oedema – with build-up of fluid from the feet upwards. The patient may notice that their shoes are tighter, ‘sock marks’ at the top of the socks, general swelling/tightness of the skin and/or pitting oedema (leaving the thumbprint after pressing)
Abdominal bloating – with discomfort, loss of appetite and symptoms of breathlessness of bending over for example tying shoelaces, gardening
Pulmonary oedema – or ‘fluid on the lungs’ with increasing symptoms of shortness of breath, cough, difficulty lying flat in bed or waking due to breathlessness, sleeping with extra pillows or more propped up in the bed or even sleeping in a chair.
The aim is to gradually remove the accumulated fluid – no more than 1-2kg/day – as more rapid diuresis can lead to acute kidney injury (AKI). It is helpful if the patient can self-monitor by both reporting on symptoms and by measuring their weight each morning. The rationale for the weights is as an assessment of change in congestion with the weight decreasing as the fluid is removed, or conversely still increasing if the treatment is not effective.
| Table 1: Commonly prescribed heart failure medicines | ||||
| Drug/drug class | Starting out | Target dose | Side-effects | Monitoring |
|
Angiotensin-converting enzyme inhibitors (ACEIs) (e.g., ramipril) |
Small initial dose titrated to maximum tolerated |
For ramipril: 10mg/day or maximum tolerated dose Hyperkalaemia Cough Angio-oedema |
Hypertension Renal impairment and electrolytes |
Blood pressure Blood tests* for renal function |
|
Angiotensin receptor blockers (ARB) (e.g., losartan) |
Small initial dose titrated to maximum tolerated |
For candesatan: 32mg/day or maximum tolerated dose Hyperkalaemia |
Hypertension Renal impairment and electrolytes |
Blood pressure Blood tests* for renal function |
|
Angiotensin receptor-neprilysin Inhibitor (ARNi) Sacubitril + valsartan |
Initial dose depends on blood pressure and previous dose of ACEi/ARB | Sacubitril + valsartan 97/101mg twice a day or maximum tolerated dose |
Hypotension Renal impairment Hyperkalaemia Diuresis |
Blood pressure Blood tests* for renal function and electrolytes Fluid status – may need dose of diuretic reduced |
| Beta blocker (e.g., bisoprolol) | Small initial dose titrated to maximum tolerated | For bisoprolol: 10mg/day or maximum tolerated dose |
Hypotension Bradycardia Cold extremities Fatigue |
Blood pressure Heart rate (pulse) |
|
Aldosterone receptor antagonists (MRA) Spironolactone or eplerenone |
12.5-25mg once a day. | 12.5-50mg once a day depending on symptoms, renal function and potassium |
Hypotension Renal impairment Hyperkalaemia Gynecomastia (spironolactone) |
Blood pressure Blood tests* for renal function and electrolytes Fluid status – may need dose of diuretic reduced |
| Sodium-glucose cotransporter-2 (SGLT2) inhibitors dapagliflozin or empagliflozin |
Dapagliflozin or empagliflozin 10mg once day |
10mg once a day |
Urinary tract infection Urinary frequency Genital thrush Fournier's gangrene (rare) DKA – including euglycemic DKA |
Blood pressure Fluid status Blood test for renal function and electrolytes at baseline HbA1c at baseline |
| Ivabradine | 2.5-5mg twice a day |
2.5-7.5mg twice a day Visual phosphenes |
Bradycardia |
Heart rate (pulse) Visual changes (phosphenes) |
*A baseline assessment of renal function is needed before starting treatment. This should be repeated one to two weeks after starting and each time the dose is increased. Ongoing monitoring will be required. For a patient with a new prescription, it is useful to ask what follow-up is in place and if they have been asked to have any blood tests.