Mineralocorticoid Receptor Antagonists (MRA)

  • An MRA is recommended for patients with persisting symptoms (NYHA Class II–IV) and an EF ≤35% despite therapy with an ACE inhibitor (or ARB) and a beta-blocker  (Class I; Level A recommendation)
  • Ensure adequate renal function and serum potassium levels prior to initiation and monitor frequently during therapy

Diuretics

  • Recommended to relieve dyspnea and edema in patients with signs and symptoms of congestion, irrespective of EF
      • Loops diuretics produce more intense, shorter dieresis than thiazides and are preferred in heart failure with reduced ejection fraction
      • Thiazides may be less effective in reduced kidney function
      • Loop diuretics and thiazides act synergistically and may be used in combination (generally temporarily) to treat resistant edema
      • Adjust dose of diuretics, particularly following restoration of dry body weight, to minimize the risk of dehydration, hypotension, and renal dysfunction

OTHER TREATMENTS WITH LESS CERTAIN BENEFITS IN SYSTOLIC HEART FAILURE

Angiotensin-Receptor Blockers (ARB)


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  • Recommended in patients with an EF ≤40% and unable to tolerate an ACE inhibitor because of cough (patients should also receive a beta-blocker and an MRA) (Class I; Level A recommendation)
  • Recommended in patients with an EF ≤40% and persisting symptoms (NYHA Class II–IV) despite treatment with an ACEI and a beta-blocker who are unable to tolerate an MRA (Class I; Level A recommendation)

Ivabradine

  • Should be considered in patients in sinus rhythm with an EF ≤35%, a heart rate remaining ≥70 bpm, and persisting symptoms (NYHA Class II–IV) despite treatment with an evidence-based dose of beta-blocker (or maximum tolerated dose below that), ACEI (or ARB), and an MRA (or ARB) (Class IIa; Level B recommendation)
  • May be considered in patients in sinus rhythm with an EF ≤35% and a heart rate ≥70 bpm who are unable to tolerate a beta-blocker. Patients should also receive an ACE inhibitor (or ARB) and an MRA (or ARB) (Class IIb; Level C recommendation)