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Therapy: Patients With Current or Prior Symptoms of HF (Stage C)
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Overview of Stage C

Stage C
Structural heart disease with prior or current symptoms of HF
e.g., Patients with:
-  known structural heart disease
and
-  shortness of breath and fatigue, reduced
exercise tolerance
Goals
-  All measures under Stages A and B
-  Dietary salt restriction
Drugs for Routine Use
-  Diuretics for fluid retention
-  ACEI
-  Beta-blockers
Drugs in Selected Patients
-  Aldosterone antagonist
-  ARBs
-  Digitalis
-  Hydralazine/nitrates
Devices in Selected Patients
-  Biventricular pacing
-  Implantable defibrillators

Summary of therapy options -  Stage C

Patients With Current or Prior Symptoms of HF (Stage C)

1. Patients With Reduced LVEF Measures listed as Class I recommendations for patients in stages A or B are also appropriate for patients with current or prior symptoms of HF (also see Section V). In addition, moderate sodium restriction, along with daily measurement of weight, is indicated to permit effective use of lower and safer doses of diuretic drugs, even if overt sodium retention can be controlled by the use of diuretics. Immunization with influenza and pneumococcal vaccines may reduce the risk of a respiratory infection. Although most patients should not participate in heavy labor or exhaustive sports, physical activity should be encouraged (except during periods of acute exacerbation of the signs and symptoms of HF or in patients with suspected myocarditis), because restriction of activity promotes physical deconditioning, which may adversely affect clinical status and contribute to the exercise intolerance of patients with HF.

Recommendations

Class I 

1. Measures listed as Class I recommendations for patients in stages A and B are also appropriate for patients in Stage C. (Levels of Evidence: A, B, and C as appropriate)

2. Diuretics and salt restriction are indicated in patients with current or prior symptoms of HF and reduced LVEF who have evidence of fluid retention (see Table 4). (Level of Evidence: C)

3. Angiotensin converting enzyme inhibitors are recommended for all patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated (See drug tables at bottom). (Level of Evidence: A)

4. Beta-blockers (using one of the three proven to reduce mortality, ie. bisoprolol, carvedilol, and sustained release metoprolol succinate) are recommended for all stable patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated. (Level of Evidence: A)

5. Angiotensin II receptor blockers approved for the treatment of HF (see Tables) are recommended in patients with current or prior symptoms of HF and reduced LVEF who are intolerant of angiotensin converting enzyme inhibitors (see full-text guideline for information regarding patients with angioedema). (Level of Evidence: A)

6. Drugs known to adversely affect the clinical status of patients with current or prior symptoms of HF and reduced LVEF should be avoided or withdrawn whenever possible (e.g., nonsteroidal anti-inflammatory drugs, most antiarrhythmic drugs, and most calcium channel blocking drugs; see full-text guideline). (Level of Evidence: B)

7. Maximal exercise testing with or without measurement of respiratory gas exchange is recommended to facilitate prescription of an appropriate exercise program for patients presenting with HF. (Level of Evidence: C)

8. Exercise training is beneficial as an adjunctive approach to improve clinical status in ambulatory patients with current or prior symptoms of HF and reduced LVEF. (Level of Evidence: B)

9. An implantable cardioverter-defibrillator is recommended as secondary prevention to prolong survival in patients with current or prior symptoms of HF and reduced LVEF who have a history of cardiac arrest, ventricular fibrillation, or hemodynamically destabilizing ventricular tachycardia. (Level of Evidence: A)

10. Implantable cardioverter-defibrillator therapy is recommended for primary prevention to reduce total mortality by a reduction in sudden cardiac death in patients with ischemic heart disease who are at least 40 days post-MI, have an LVEF less than or equal to 30%, with New York Heart Association functional class II or III symptoms, while undergoing chronic optimal medical therapy, and have reasonable expectation of survival with a good functional status for more than 1 year. (Level of Evidence: A)

11. Implantable cardioverter-defibrillator therapy is recommended for primary prevention to reduce total mortality by a reduction in sudden cardiac death in patients with nonischemic cardiomyopathy who have an LVEF less than or equal to 30%, with New York Heart Association functional class II or III symptoms while undergoing chronic optimal medical therapy, and have reasonable expectation of survival with a good functional status for more than 1 year. (Level of Evidence: B)

12. Patients with LVEFs less than or equal to 35%, sinus rhythm, and New York Heart Association functional class III or ambulatory class IV symptoms despite recommended, optimal medical therapy and who have cardiac dyssynchrony, which is currently defined as a QRS duration greater than 120 ms, should receive cardiac resynchronization therapy unless contraindicated. (Level of Evidence: A)

13. Addition of an aldosterone antagonist is recommended in selected patients with moderately severe to severe symptoms of HF and reduced LVEF who can be carefully monitored for preserved renal function and normal potassium concentration. Creatinine should be less than or equal to 2.5 mg/dL in men or less than or equal to 2.0 mg/dL in women and potassium should be less than 5.0 mEq/L. Under circumstances where monitoring for hyperkalemia or renal dysfunction is not anticipated to be feasible, the risks may outweigh the benefits of aldosterone antagonists. (Level of Evidence: B)

 

Class IIa

1. Angiotensin II receptor blockers are reasonable to use as alternatives to angiotensin converting enzyme inhibitors as first-line therapy for patients with mild to moderate HF and reduced LVEF, especially for patients already taking angiotensin II receptor blockers for other indications. (Level of Evidence: A)

2. Digitalis can be beneficial in patients with current or prior symptoms of HF and reduced LVEF to decrease hospitalizations for HF. (Level of Evidence: B)

3. The addition of a combination of hydralazine and a nitrate is reasonable for patients with reduced LVEF who are already taking an angiotensin converting enzyme inhibitor and beta-blocker for symptomatic HF and who have persistent symptoms. (Level of Evidence: B)

4. Placement of an implantable cardioverterdefibrillator is reasonable in patients with LVEF of 30% to 35% of any origin with New York Heart Association functional class II or III symptoms who are taking chronic optimal medical therapy and who have reasonable expectation of survival with good functional status of more than 1 year. (Level of Evidence: B)

 

Class IIb

1. A combination of hydralazine and a nitrate might be reasonable in patients with current or prior symptoms of HF and reduced LVEF who cannot be given an angiotensin converting enzyme inhibitor or angiotensin II receptor blocker because of drug intolerance, hypotension, or renal insufficiency. (Level of Evidence: C)

2. The addition of an angiotensin II receptor blocker may be considered in persistently symptomatic patients with reduced LVEF who are already being treated with conventional therapy. (Level of Evidence: B)

 

Class III

1. Routine combined use of an angiotensin converting enzyme inhibitor, an angiotensin II receptor blocker, and an aldosterone antagonist is not recommended for patients with current or prior symptoms of HF and reduced LVEF. (Level of Evidence: C)

2. Calcium channel blocking drugs are not indicated as routine treatment for HF in patients with current or prior symptoms of HF and reduced LVEF. (Level of Evidence: A)

3. Long-term use of an infusion of a positive inotropic drug may be harmful and is not recommended for patients with current or prior symptoms of HF and reduced LVEF, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment (see recommendations for Stage D). (Level of Evidence: C)

4. Use of nutritional supplements as treatment for HF is not indicated in patients with current or prior symptoms of HF and reduced LVEF. (Level of Evidence: C)

5. Hormonal therapies other than to replete deficiencies are not recommended and may be harmful to patients with current or prior symptoms of HF and reduced LVEF. (Level of Evidence: C)

Oral Diuretics Recommended for Use in the Treatment of Chronic Heart Failure

Drug Initial Daily Dose(s) Maximum Total Daily Dose Duration of action
Loop Diuretics
Bumetanide Oral: 0.5 to 1 mg qd-bid 10 mg 4 to 6 hours
Furosemide Oral: 20 to 40 mg qd-bid 600 mg 6 to 8 hours
Torsemide Oral: 10 to 20 mg qd 200 mg 12 to 16 hours
Thiazide Diuretics
Chlorthiazide 250-500 mg qd-bid 1000 mg 6 to 12 hours
Chlorthalidone 12.5 to 25 mg qd 100 mg 24 to 72 hours
Hydrochlorothiazide 25 mg qd - bid 200 mg 6 to 12 hours
Indapamide 2.5 mg qd 5 mg 36 hours
Metolazone 2.5 mg qd 20 mg 12 to 24 hours
Potassium-sparing diuretics
Amiloride 5 mg qd 20 mg 24 hours
Spironolactone 12.5 to 25 mg qd 50 mg (possibly higher doses in select cases) 2 to 3 days
Triamterene 50 to 75 mg bid 200 mg 7 to 9 hours
Sequential Nephron blockade
Metolazone 2.5 to 10 mg qd plus loop diuretic
Hydrochlorothiazide 25 to 100 mg qd-bid plus loop diuretic
Chlorthiazide (IV) 500 to 1000 mg qd plus loop diuretic
Intravenous Diuretic Medications Useful for the Treatment of Severe Heart Failure
Loop Diuretics
Drug Initial dose Max single dose  
Bumetanide 1 mg 4 to 8 mg  
Furosemide 40 mg 160 to 200 mg  
Torsemide 10 mg 100 to 200 mg  
Thiazide Diuretics
Chlorthiazide 500mg 1000 mg  
Intravenous Infusions
Bumetanide 1 mg IV load, then 0.5 to 2 mg per hour
Furosemide 40 mg IV load, then 10 to 40 mg per hour
Torsemide 20 mg IV load, then 5 to 20 mg per hour

Medications Commonly Used for the Treatment of Patients with Heart Failure with Low Ejection Fraction
Drug Initial Daily Dose(s) Maximum Dose(s)
ACE-Inhibitors
Captopril 6.25 mg tid 50mg tid
Enalapril 2.5 mg bid 10 to 20 mg bid
Fosinopril 5 to 10mg qd 40mg qd
Lisinopril 2.5 to 5 mg qd 20 to 40 mg qd
Perindopril 2 mg qd 8 to 16 mg qd
Quinapril 5 mg bid 20 mg bid
Ramipril 1.25 to 2.5 mg qd 10mg qd
Trandolapril 1 mg qd 4 mg qd
Angiotensin Receptor Blockers
Candesartan 4 to 8 mg qd 32 mg qd
Losartan 25 to 50 mg qd 50 to 100 mg qd
Valsartan 20 to 40 mg bid 160 mg bid
Aldosterone Antagonists
Spironolactone 12.5 to 25 mg qd 25 mg qd to bid
Eplerenone 25 mg qd 50 mg qd
Beta-Blockers
Bisprolol 1.25 mg qd 10 mg qd
Carvedilol 3.125 mg bid 25 mg bid. 50mg bid for patients > 85 kg.
Metoprolol succinate extended release 12.5 to 25 mg qd 200mg qd

Reference

Direct quotes from this valuable reference:
Hunt SA, Abraham WT, Chin MH, Feldman AM, et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20;112(12):e154-235. Epub 2005.  
Link: http://circ.ahajournals.org/cgi/content/full/112/12/e154

Disclaimer

All calculations must be confirmed before use. The authors make no claims of the accuracy of the information contained herein; and these suggested doses are not a substitute for clinical judgement. Neither GlobalRPh Inc. nor any other party involved in the preparation of this program shall be liable for any special, consequential, or exemplary damages resulting in whole or part from any user's use of or reliance upon this material.PLEASE READ THE DISCLAIMER CAREFULLY BEFORE ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER.   Read the disclaimer
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