General guidelines for medications used for heart failure can be found in national and international guidelines:
NICE guideline- Chronic heart failure in adults: diagnosis and management. Quite brief with useful general advice about heart failure.
European Society of Cardiology HF Guideline: much lengthier document with a lot more detail .
The below notes relate to specific local arrangements.
Ramipril is the first line ACE inhibitor in Oxfordshire. It is usually prescribed od. Some patients seem to do better with divided dosing. Postural light headedness can often be improved by taking at night. The target dose is 10mg; as with all ACE inhibitors the greatest prognostic and symptomatic benefit is achieved by titrating up to the maximum tolerated dose.
Lisinopril and Perindopril are also freely prescribable in Oxfordshire for heart failure. Oxfordshire formulary link.
Angiotensin Receptor Blockers (ARB)
These have been shown to be equivalent to ACE inhibitors for patients with heart failure with a reduced ejection fraction. Candesartan is the first line ARB for heart failure in Oxfordshire. The target dose is 32mg.
Losartan can also be used in heart failure., with a target dose of 150mg. Oxfordshire formulary link.
There are only a few beta blockers which have an evidence base for treatment of heart failure with reduced ejection fraction.
We usually use bisoprolol as first line, due to the ease of once daily dosing. The target dose is 10mg; as with all beta blockers the greatest prognostic and symptomatic benefit is achieved by titrating up to the maximum tolerated dose.
Carvedilol is a good alternative, which is prescribed bd and titrated to a target dose of 25mg BD. It has some additional vasodilatory properties mediated via α receptors.
Nebivolol may be better tolerated in some patients from the respiratory and erectile point of view. It has been approved for prescribing in Oxfordshire as a third line option if the others are not tolerated
Beta blockers are safe to use in patients with COPD, and indeed may have additional benefits in these patients. In patients with genuine reactive asthma, more care may need to be taken, but many patients with asthma will tolerate Nebivolol.
Mineralocorticoid Receptor Antagonists
These are a key treatment in heart failure. The evidence base strongly supports prognostic benefit in heart failure with reduced ejection fraction, but we often suggest them as an adjunctive diuretic in heart failure with preserved ejection fraction. Potassium levels should be monitored after initiation.
Spironolactone is first line in females. The target dose is 25mg od in heart failure with reduced ejection fraction, though we sometimes use higher doses when required. 12.5mg tablets are not manufactured, so prescription of this dose will usually entail cutting tablets in half, which is very difficult for many patients, and not usually recommended. Eplerenone 25mg is equivalent to spironolactone 12.5mg and a more practical option.
Eplerenone has a lower risk of causing gynaecomastia and so we recommend it as first line for males (particularly if <65 years). The target dose in heart failure with reduced ejection fraction is higher – 50mg od. It is normally started at 25mg od and should be uptitrated to 50mg od when possible.
Sacubitril/Valsartan (Angiotensin receptor neprilysin inhibitor; ARNI)
Sacubitril/Valsartan (Entresto) is used to treat heart failure with reduced ejection fraction, replacing an ACE inhibitor or ARB (which must NOT be prescribed with Entresto). It has been shown be superior to an ACE inhibitor in reducing mortality and morbidity in this population.
In Oxfordshire it is subject to prescribing arrangements as set out in the shared care protocol.
Dapagliflozin and empagliflozin have licences and are recommended by NICE for use in heart failure with a reduced ejection fraction, added to optimised therapy with ACE/ARB/ARNI, Beta blocker, and aldosterone antagonist. Dapagliflozin has been approved by NICE for patients with ejection fraction above 40%. See the local guideline for more detail and specific advice.
Studies have shown considerable benefit when patients with heart failure (with or without diabetes) were treated with Dapagliflozin or Empagliflozin. Other SGLT-2 inhibitors are also the subject of current trials in HF patients.
The benefit of these drugs is independent of ejection fraction, and both dapagliflozin and empagliflozin are licenced for use in heart failure at any ejection fraction, but only dapagliflozin has NICE approval for this indication (Sept 2023).
Canagliflozin (Invocana), Dapagliflozin (Forxiga), Empagliflozin (Jardiance), and ertugliflozin (Steglatro) are licenced for the treatment of Type 2 Diabetes. Several studies have shown significant improvement in cardiovascular outcomes including heart failure.
Intravenous Iron Infusions
Iron deficiency is common in heart failure. It may be relative rather than absolute (i.e. low transferrin saturations without very low ferritin). Oral iron does not seem to result in symptomatic benefits in the context of heart failure, but intravenous iron does (even in the absence of anaemia).
In patients with heart failure and a reduced ejection fraction, please consider checking iron studies.
- Intravenous iron is recommended in these
patients if they have low iron levels as shown by:
- Serum ferritin less than 100 µg/L OR
- Serum ferritin between 100 and 299µg/L and transferrin saturations less than 20%