CHF 2: medications

Tina revisits ACEI, ARB, BB, and Thiazides, which were covered previously with the hypertension episodes, and introduces a few new medications as well:

Mineralocorticoid Receptor Antagonists: spironolactone and eplerenone

Loop diuretic: furosemide

Digoxin

Vasodilators: hydralazine and isosorbite dinitrate

For a quick summary of the CCS 2013 recommendations:

ACE inhibitors:

all asymptomatic patients with an EF < 35%

all symptomatic HF patients and EF < 40%

ARB:

if intolerant to ACEI

add to ACEI if intolerant or contraindicated for BB

add to ACEI and BB if NYHA class II-IV HF and EF ≤ 40% deemed at increased risk of HF events

BB:

all HF patients with an EF ≤ 40%

initiated at a low dose and titrated to the target dose or maximal tolerated dose

MRA:

patients > 55 years with mild to moderate HF during standard HF treatments with EF ≤ 30% (or ≤ 35% if QRS duration > 130 ms) and recent (6 months) hospitalization for CV disease or

with elevated BNP or NT-proBNP levels

after an MI with EF ≤ 30% and HF or

EF ≤ 30% alone in the presence of diabetes

EF < 30% and severe chronic HF (NYHA IIIB-IV) despite optimization of other recommended treatments

Diuretics:

for congestive symptoms

When acute congestion is cleared, the lowest dose should be used that is compatible with stable signs and symptoms

persistent volume overload despite optimal medical therapy and increases in loop diuretics, cautious addition of a second diuretic (a thiazide or low dose metolazone) may be considered as long as it is possible to closely monitor morning weight, renal function, and serum potassium

Digoxin:

patients in sinus rhythm who continue to have moderate to severe symptoms, despite optimized HF therapy

patients with chronic atrial fibrillation (AF) and poor control of ventricular rate

Isosorbide dinitrate and hydralazine:

black Canadians with HF-REF

non-black HF patients unable to tolerate an ACE inhibitor or ARB

Drug information from:

Drug monographs

CPS: http://www.e-therapeutics.ca/

Therapeutic Choices: http://www.e-therapeutics.ca/

Rx Files: http://www.rxfiles.ca/rxfiles/modules/druginfoindex/druginfo.aspx