Heart Failure [ACCF/AHA]

Heart Failure

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Treatment Diuretics (see Table 13) ÎÎDiuretics are recommended in patients with HFr EF who have evidence of fluid retention, unless contraindicated, to improve symptoms. (I-C) ACE Inhibitors ÎÎACE inhibitors are recommended in patients with HFr EF and current or prior symptoms, unless contraindicated, to reduce morbidity and mortality. (I-A) ARBs ÎÎARBs are recommended in patients with HFr EF with current or prior symptoms who are ACE inhibitor–intolerant, unless contraindicated, to reduce morbidity and mortality. (I-A) ÎÎARBs are reasonable to reduce morbidity and mortality as alternatives to ACE inhibitors as first-line therapy for patients with HFr EF, especially for patients already taking ARBs for other indications, unless contraindicated. (IIa-A) ÎÎAddition of an ARB may be considered in persistently symptomatic patients with HFr EF who are already being treated with an ACE inhibitor and a beta blocker in whom an aldosterone antagonist is not indicated or tolerated. (IIb-A) ÎÎRoutine combined use of an ACE inhibitor, ARB, and aldosterone antagonist is potentially harmful for patients with HFr EF. (III-C: Harm) Beta Blockers ÎÎUse of 1 of the 3 beta blockers proven to reduce mortality (ie, bisoprolol, carvedilol, and sustained-release metoprolol succinate) is recommended for all patients with current or prior symptoms of HFr EF, unless contraindicated, to reduce morbidity and mortality. (I-A) Aldosterone Receptor Antagonists (see Table 15) ÎÎAldosterone receptor antagonists (or mineralocorticoid receptor antagonists) are recommended in patients with NYHA class II–IV and who have LVEF of 35% or less, unless contraindicated, to reduce morbidity and mortality. Patients with NYHA class II should have a history of prior cardiovascular hospitalization or elevated plasma natriuretic peptide levels to be considered for aldosterone receptor antagonists. Creatinine levels should be 2.5 mg/dL or less in men or 2.0 mg/dL or less in women (or estimated glomerular filtration rate >30 mL/min/1.73 m2) and potassium levels should be less than 5.0 mEq/L. Careful monitoring of potassium levels, renal function, and diuretic dosing should be performed at initiation and closely followed thereafter to minimize risk of hyperkalemia and renal insufficiency. (I-A) 20

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