23
Diuretics (see Table 15)
Î Diuretics are recommended in patients with HFr EF who have evidence
of fluid retention, unless contraindicated, to improve symptoms. (I-C)
ACE Inhibitors
Î ACE inhibitors are recommended in patients with HFr EF and current
or prior symptoms, unless contraindicated, to reduce morbidity and
mortality. (I-A)
ARBs
Î ARBs 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)
Î ARBs 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)
Î Addition 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)
Î Routine combined use of an ACE inhibitor, ARB, and aldosterone
antagonist is potentially harmful for patients with HFr EF. (III-C: Harm)
Beta Blockers
Î Use 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 17)
Î Aldosterone receptor antagonists (or mineralocorticoid receptor
antagonists) are recommended in patients with NYHA class II–IV and
who have LVEF of ≤35%, 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 in men or ≤2.0 mg/dL in
women (or estimated glomerular filtration rate >30 mL/min/1.73 m
2
)
and potassium levels should be <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)
