Heart Failure Quick Guide

Find medication information including dosages and medications to avoid, preventive care guidelines for your heart failure patients, information about ischemic evaluation and heart failure with preserved ejection fraction (HFpEF). 

Not sure when to refer to specialty care? We have a quick guide for that. 

Ready to take the next steps to excellence in managing heart failure in primary care? Review the Mount Sinai Heart Failure Care Pathway or discover services available to MSHP Clinically Integrated Network providers to achieve team-based care. 

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Medications

Starting and Target Doses of Select Guideline-Directed Medical Therapy (GDMT) for HF

  Starting Dose Target Dose

ARNI

   
Sacubitril/valsartan 24/26 mg - 49/51 mg 2x daily 97/103 mg 2x daily

ACEI

   
Captopril 6.25 mg 3x daily 50 mg 3x daily
Enalapril 2.5 mg 2x daily 10-20 mg 2x daily
Lisinopril 2.5-5 mg daily 20-40 mg daily
Ramipril 1.25 mg daily 10 mg daily

ARB

   
Candesartan 4-8mg daily 32mg daily
Losartan 25-50 mg daily 150 mg daily
Valsartan 40 mg 2x daily 160mg 2x daily

Beta Blockers

   
Bisoprolol 1.25 mg daily 10 mg daily
Carvedilol 3.125 mg 2x daily 25 mg 2x daily for weight <85kg; 50 mg daily for weight =85 kg
Metoprolol succinate* 12.5 - 25 mg daily 200 mg daily

Aldosterone Antagonists

   
Eplerenone 25 mg daily 50 mg daily
Spironolactone 12.5 - 25 mg daily 25-50 mg daily

SGLT2 Inhibitors

   
Dapagliflozin 10 mg daily 10 mg daily
Empagliflozin 10 mg daily 10 mg daily

Vasodilators

   
Hydralazine 25 mg 3x daily 75 mg 3x daily
Isosorbide dinitrate 20 mg 3x daily 40 mg 3x daily
Fixed-dose combination isosorbide dinitrate/hydralazine 20 mg/37.5 mg (one tab) 3x daily 2 tabs 3x daily

Ivabradine

   
Ivabradine 2.5-5 mg 2x daily 10 mg daily

Diuretics — Loop

   
Bumetanide 0.5 - 1 mg 1x or 2x daily 10 mg daily
Furosemide 20-40 mg 1x or 2x daily 400 mg daily
Torsemide 10-20 mg daily 200 mg daily

Digoxin

   
Digoxin 0.125 mg daily 0.25 mg daily
*Unlike immediate-releases metoprolol, metoprolol ER is proven to improve symptoms of heart failure, lower the risk of death from heart failure, and lower the risk of hospitalization due to heart problems. While atenolol is technically another hypertension drug, it doesn't have these additional benefits. 

 

Medications to Avoid in Heart Failure Patients

NSAIDs in all types of HF
Second generation calcium channel blockers such as amlodopine may be used for blood pressire control in HFrEF. Other calcium channel blockers such as verapamil, diltiazem, and nifedipine should be avoided in patients with HFrEF.
Nitrates in HFpEF

 

Medication questions? Contact the MSHP Pharmacy Team.


Preventive Care

Vaccinations for Heart Failure Patients

Influenza vaccine

Recommended for all patients with HF

Pneumococcal vaccine

The PPSV23 is recommended for all adult patients with heart failure. Administration of PCV13 should also be considered for patients = 65 years old

 

When to Refer to a Specialist

  • New-onset HF (regardless of EF): Refer for evaluation of etiology, guideline-directed evaluation and management of recommended therapies, and assistance in disease management, including consideration of advanced imaging, endomyocardial biopsy, or genetic testing for primary evaluation of new-onset HF

  • Chronic HF with high-risk features, such as development of 1 more of the following risk factors:

     

    • Need for chronic IV inotropes

    • Persistent NYHA functional class III-IV symptoms

    • Systolic blood pressure =90 mm Hg or symptomatic hypotension

    • Creatinine =1.8 mg/dl or BUN =43 mg/dl

    • Onset of atrial fibrillation, ventricular arrthymias, or repetitive ICD shocks

    • Two or more ED visits or hospitalizations for worsening HF in prior 12 months

    • Inability to tolerate optimally dosed beta-blockers and/or ACI/ARB/ARNU and/or aldosterone antagonists

    • Clinical deterioration, as indicated by worsening edema, rising biomarkers (BNP, NT-proBNP, others), worsened exercise testing, decompensated hemodynamics, or evidence of progressive re-modeling on imaging

    • High mortality risk using a validated risk model for further assessment and consideration of advanced therapies, such as Seattle Heart Failure Model

  • To assist with management of GDMT, including replacement of ACEI or ARB therapy with ARNI for eligible patients or to address comorbid conditions such as chronic renal disease or hyperkalemia, which may complicate treatment.

  • Persistent reduced LVEF at or below 35% despite GDMT for at least 3 months for consideration of device therapy in those patients without prior placement of ICD or CRT, unless device therapy contraindicated or inconsistent with overall goals of care

  • Annual review of patients with established advanced HF in which patients/caregivers and clinicians discuss current and potential therapies for both anticipated and unanticipated events, possible HF disease trajectory and prognosis, patient preferences, and advanced care planning.

  • Assessment of patient for possible participation in a clinical trial

Find a cardiologist

 

Heart Failure with Preserved Ejection Fraction (HFpEF)

HFpEF treatment focuses on maintaining euvolemia and effectively managing associated comorbidities (coronary artery disease, hypertension, atrial fibrilation, diabetes mellitus, obstructive sleep apnea)

 

Next Steps

Read the Mount Sinai Heart Failure Pathway for in-depth, evidence-based guidelines for managing your heart failure outpatients

Explore Team-Based Care services available to you and your practice as a member of MSHP's Clinically Integrated Network

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