Drugs used in Heart Failure

Question 1

1. Diuretics

Answer 1

Relieve symptoms of HF

Loop - Furosemide or Bumetanide

Question 2

What are side effects of (loop) diuretics?

Answer 2

Decreased K+

Renal impairment

Question 3

How should diuretics be managed?

Answer 3

Monitor U&Es

Question 4

When should K+ sparring be added?

Answer 4

Spironolactone 
If K+ <3.2
Predisposition to arrhythmias
Concurrent digoxin therapy 
Pre-existing K+ losing conditions

Question 5

When should you consider thiazide?

Answer 5

Refractory oedema

Metolazone 5-20mg/24h PO

Question 6

2. ACEi

Answer 6

Consider in all those with LVSD
Improve symptoms and prolongs life
If cough is problem then try ARB

Question 7

What are side effects of ACEi?

Answer 7

Cough

Increased K+

Question 8

3. BB

Answer 8

Carvedilol
Decreases mortality in HF
Beneficial addition to ACEi for SD
Use with caution - start low and go slow
Wait over 2 weeks between each dose increment

Question 9

4. Mineralocorticoid receptor antagonists

Answer 9

Spironolactone
Eplerenone is alternative if not tolerated

Decreases mortality when combined in therapy
Used if still symptomatic despite previous therapy and post-MI

Question 10

What needs to be considered with Spironolactone?

Answer 10

Risk of hyperkalaemia
Risk is small
But monitor U&Es
Particularly if known CKD

Question 11

5. Digoxin

Answer 11

Helps symptoms even if sinus rhythm
Consider if LVSD on standard therapy and still have S+S
Use in px with AF

Question 12

What need to be considered with digoxin?

Answer 12

Monitor U&Es
Maintain K+ at 4.5 as decreased K+ risks digoxin toxicity and vice versa
Note that other inotropes are unhelpful in terms of outcome

Question 13

6. Vasodilators

Answer 13

Hydralazine + Isosorbide dinitrate
Use if intolerant to ACEi and ARBs

Reduces mortality when combined in standard therapy for black pxs