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Table 124-1

Therapy for Chronic Heart Failure

  1. General measures
    1. Restrict salt intake
    2. Avoid NSAIDs
    3. Immunize against influenza and pneumococcal pneumonia
  2. Diuretics
    1. Use in volume-overloaded pts to achieve normal JVP and relief of edema
    2. Weigh daily to adjust dose
    3. For diuretic resistance, administer IV or use 2 diuretics in combination (e.g., furosemide plus metolazone)
  3. ACE inhibitor or angiotensin receptor blocker
    1. For all pts with LV systolic heart failure or asymptomatic LV dysfunction
    2. Contraindications: Serum K+ >5.5, advanced renal disease (e.g., creatinine >3 mg/dL), bilateral renal artery stenosis, pregnancy
  4. Beta blocker
    1. For pts with symptomatic or asymptomatic heart failure and LVEF <40%, combined with ACE inhibitor and diuretics
    2. Contraindications: Bronchospasm, symptomatic bradycardia or advanced heart block, unstable heart failure
  5. Aldosterone antagonist
    1. Consider for class II-IV heart failure and LVEF <35%
    2. Avoid if K+ >5.0 or creatinine >2.5 mg/dL
  6. Digitalis
    1. For persistently symptomatic pts with systolic heart failure (especially if atrial fibrillation present) added to ACE inhibitor, diuretics, beta blocker
  7. Other measures
    1. Consider combination of hydralazine and oral nitrate if not tolerant of ACE inhibitor/ARB
    2. Consider ivabradine for LVEF ≤35%, if in sinus rhythm, rate > 70, already on maximum tolerated beta blocker, or if contraindication to beta-blocker
    3. Consider ventricular resynchronization (biventricular pacemaker) for pts with class III or IV heart failure, LVEF <35%, and QRS >120 ms
    4. Consider implantable cardioverter-defibrillator in pts with class II-III heart failure and ejection fraction <35%