DrugsinHeartFailure in afya

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(see NICE diagram)

''ACEi and BB''
(if LV systolic function is impaired) for all at closest to max dose poss
ACEi prior to BB

then with specialist advice, 
add Spironolactone (esp if recent MI) or ARB (may cause angioedema) 
or Hydralazine with Nitrates (esp if afro-caribean or intolerant to ACE/ARB)

''Diuretic'' if fluid overload so may help Sx but doesn't change prognosis so other drugs 1st

In elderly there is more tolerance to drugs and inc need to monitour for SE
If young and female remember to discuss pregnancy
''Digoxin'' useful if Sx (esp if AF) but doesn't change prognosis
If persistent Sx - offer cardiac resynchronisation or digoxin
Offer annual flu jab and one off pneumo jab (boost 5yrly if asplenia, spleen dysfunction or CKD)

''Spironolactone''
Gynaecomastia, hyperkalaemia, occ osteomalacia

''Hydralazine''
drug induced lupus - arthralgia, weight loss and raised ANA

''ACEi''
If intolerable (stops sleep) cough with ACE use ARB and monitour for renal failure and inc K (remember cough may be associated lung disease or pulmonary oedema)

''BB (licensed for HF)''
''can'' be used in DM, COPD without reversibility, erectile dysfunction, PVD and interstitial ling disease
start low, inc slow, check Sx, pulse and BP
may get transient pulmonary congestion on start or inc dose - persevere if not distressed and manage with diuretics
light headed, bradycardia, low BP - too high dose - go back to previous OK and inc in smaller amount

''Amlodipine''
for co-existent HT / angina
AVOID Diltiazem, Verpamil and Nifedipine

''Digoxin''
use if still Sx despite 1st and 2nd line Rx
mostly effective at rest but may help exercise tolerance if not in AF
Toxicity - yellow vision, nausea, headache, slow pulse (routine levels not useful)
dec levels by antacids, st johns wort and sulphsalazine

''Amiodarone''
should be started by specialist and reviewed regularly
6/12 TFT, LFT, pulmonary function, clinical and SE
inc levels by amiodarone

''AVOID - as may exacerbate failure''
Pioglitazone (fluid retention)
Verapamil (negative inotrope)
NSAID / glucocorticoid (fluid retention) - low dose aspirin OK
Flecainide (negative inotrope and proarrhythmic)

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