Heart Failure

24 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)

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