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Treatment
Î Aldosterone receptor antagonists are recommended to reduce
morbidity and mortality following an acute MI in patients who have
LVEF of ≤40% who develop symptoms of HF or who have a history of
diabetes mellitus, unless contraindicated. (I-B)
Î Inappropriate use of aldosterone receptor antagonists is potentially
harmful because of life-threatening hyperkalemia or renal
insufficiency when serum creatinine is >2.5 mg/dL in men or
>2.0 mg/dL in women (or estimated glomerular filtration rate
<30 mL/min/1.73 m
2
), and/or potassium >5.0 mEq/L. (III-B: Harm)
Hydralazine and Isosorbide Dinitrate
Î The combination of hydralazine and isosorbide dinitrate is
recommended to reduce morbidity and mortality for patients self-
described as African Americans with NYHA class III–IV HFr EF
receiving optimal therapy with ACE inhibitors and beta blockers,
unless contraindicated. (I-A)
Î A combination of hydralazine and isosorbide dinitrate can be useful
to reduce morbidity or mortality in patients with current or prior
symptomatic HFr EF who cannot be given an ACE inhibitor or ARB
because of drug intolerance, hypotension, or renal insufficiency,
unless contraindicated. (IIa-B)
Digoxin
Î Digoxin can be beneficial in patients with HFr EF, unless
contraindicated, to decrease hospitalizations for HF. (IIa-B)
Anticoagulation
Î Patients with chronic HF with permanent/persistent/paroxysmal
AF and an additional risk factor for cardioembolic stroke (history of
hypertension, diabetes mellitus, previous stroke or transient ischemic
attack, or ≥75 years of age) should receive chronic anticoagulant
therapy (in the absence of contraindications to anticoagulation). (I-A)
Î The selection of an anticoagulant agent (warfarin, dabigatran,
apixaban, or rivaroxaban) for permanent/persistent/paroxysmal AF
should be individualized on the basis of risk factors, cost, tolerability,
patient preference, potential for drug interactions, and other clinical
characteristics, including time in the international normalized ratio
therapeutic range if the patient has been taking warfarin. (I-C)
Î Chronic anticoagulation is reasonable for patients with chronic HF
who have permanent/persistent/paroxysmal AF but are without an
additional risk factor for cardioembolic stroke (in the absence of
contraindications to anticoagulation). (IIa-B)
Î Anticoagulation is NOT recommended in patients with chronic HFr EF
without AF, a prior thromboembolic event, or a cardioembolic source.
(III-B: No Benefit)
