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)
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