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
- See 2.5.5 Drugs affecting the renin-angiotensin system
- The dose may be doubled at approximately two weekly intervals.
- Aim for the target dose but the use of maximum tolerated dose is likely to be more beneficial than no ACE inhibitor.
- 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.
- 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
- See 2.4 Beta-adrenoceptor blocking drugs
- The dose should be doubled at not less than two-weekly intervals.
- Aim for the target dose but the use of maximum tolerated dose is likely to be more beneficial than no beta-blocker.
- 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.