To reduce morbidity and mortality, prescribe an ACE inhibitor and a beta-blocker.

To relieve symptoms of fluid overload, prescribe a diuretic.

Loop diuretic plus ACE inhibitor plus Beta-blocker

Loop diuretic

• Diuretic therapy is likely to be required at all stages in treatment, to control symptoms of congestion and fluid retention
• Formulary choice: furosemide, bumetanide (See 2.2.2 Loop diuretics)
• If patient is already taking a thiazide diuretic for hypertension review treatment (combination can cause profound diuresis)

ACE inhibitor

Enalapril

• Starting dose: 2.5mg twice daily
• Target dose: 20mg twice daily

Lisinopril

• Starting dose: 2.5mg – 5mg daily
• Target dose: 30mg – 35mg daily

Ramipril

• Starting dose: 2.5mg daily
• Target dose: 10 daily (or 5mg twice daily post MI, switch to once daily dosing once optimum tolerated dose is reached)

Notes

1. See 2.5.5 Drugs affecting the renin-angiotensin system
2. The dose may be doubled at approximately two weekly intervals.
3. Aim for the target dose but the use of maximum tolerated dose is likely to be more beneficial than no ACE inhibitor.
4. Monitor U&E, creatinine etc. as described in 2.5.5 Drugs affecting the renin-angiotensin system. NICE considers that an increase in creatinine of up to 50% of baseline or a maximum of 200 micromol/L is acceptable.
5. If the patient experiences excessive rises in creatinine, urea and potassium, consider stopping nephrotoxic drugs, e.g. NSAIDs, vasodilators (CCB/nitrates), potassium supplements/retaining diuretics, and if there are no signs of congestion, reduce the dose of diuretic.

Beta-blocker

Bisoprolol

• Starting dose: 1.25mg daily
• Target dose: 10mg daily

Carvedilol

• Starting dose: 3.125mg twice daily
• Target dose: 25mg – 50mg twice daily
• Maximum dose of carvedilol in severe heart failure is 25mg twice daily. In mild to moderate heart failure the maximum dose in patients weighing under 85kg is 25mg twice daily, otherwise it is 50mg twice daily.

Nebivolol**

• Starting dose: 1.25mg daily
• Target dose: 10mg daily
• The nebivolol licence is restricted to the management of mild to moderate heart failure in patients over 70. The formulary position is to use this only for patients intolerant of other beta blockers.

Notes

1. See 2.4 Beta-adrenoceptor blocking drugs
2. The dose should be doubled at not less than two-weekly intervals.
3. Aim for the target dose but the use of maximum tolerated dose is likely to be more beneficial than no beta-blocker.
4. Temporary symptomatic deterioration may occur in up to 30% of cases. If there is increased congestion, double the dose of diuretic or halve the dose of beta-blocker. If there is marked fatigue or bradycardia, halve the dose of beta-blocker.

If symptoms persist despite optimal first-line therapy, seek specialist advice and consider adding:

• Aldosterone antagonists (spironolactone or eplerenone) licensed for heart failure (especially in moderate to severe heart failure or MI in past month)
• An ARB licensed for heart failure (candesartan is licensed for use in combination with ACE inhibitors, losartan is not)
• Hydralazine in combination with nitrate (especially in patients of African or Caribbean origin with moderate to severe heart failure who are unable to take an ACEi or an ARB).
• Ivabradine in combination with standard therapy or as an alternative to beta-blockers in the following patient groups:
  • with New York Heart Association (NYHA) class II to IV stable chronic heart failure with systolic dysfunction and
  • who are in sinus rhythm with a heart rate of more than 75 beats per minute (bpm) and
  • who have a left ventricular ejection fraction of 35% or less
• Dapagliflozin and empagliflozin as an add-on to optimised standard care with:
  • angiotensin-converting enzyme (ACE) inhibitors or angiotensin-2 receptor blockers (ARBs), with beta blockers, and, if tolerated, mineralocorticoid receptor antagonists (MRAs), or
  • sacubitril valsartan, with beta blockers, and, if tolerated, MRAs
  • For more information, see dapagliflozin and empagliflozin under SGLT2 inhibitors (6.1.2 Antidiabetic drugs)

If symptoms persist consider:

• Cardiac resynchronisation therapy for patient with a wide QRS complex (pacing with or without a defibrillator)
• Digoxin (for worsening or severe heart failure due to left ventricular systolic dysfunction despite first and second-line treatments).

The Heart Failure Nurse Team will accept referrals for patients with heart failure due to left ventricular systolic dysfunction, which has been confirmed by echocardiography and / or angiography. As per NICE CG108, newly suspected Heart Failure should be referred for an echocardiogram and assessment by a specialist, before referring to the Heart Failure Nurse Team.

• Northern Devon Heart Failure Nurse Team: 01271 311633
• Exeter, Mid and East Devon Heart Failure Nurse Team:
  • Email: Rde-tr.communitycardiacservice@nhs.net
  • Telephone: 01392 356159