Heart Failure

An Essential Clinical Guide

Andreas P. Kalogeropoulos, Hal A. Skopicki, Javed Butler, Andreas P. Kalogeropoulos, Hal A. Skopicki, Javed Butler

• Publisher: CRC Press
• Year: 2022
• ISBN:
  9780429534751
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This "patient-oriented" book was written as a meeting ground for practicing clinicians, allied health professionals, and clinical researchers to provide a practical guide for the contemporary assessment and management of patients with heart failure and cardiomyopathy. It revolves around broad patient scenarios to elegantly (or expertly) guide diagnostic and management strategies. Combining the talents of over one-hundred experts in the field, the book also endeavors to challenge the reader with areas of current controversies and opportunities for clinical investigation with the goals of both orienting clinicians and stimulating their research passions.

Key Features

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• Provides practical guidance based on real-life heart failure scenarios

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• Discusses both acute and chronic care patient-oriented scenarios

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• Covers up-to-date and novel concepts in heart failure

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• Features the perspectives of current debates and controversies in heart failure

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• Highlights the opportunities for research in this field

Section III
Managing Chronic Heart Failure

DOI: 10.1201/9780429244544-12

Chapter 10 Outpatient Management of Stable Heart Failure with Reduced Ejection Fraction

Chapter 11 Exercise and Rehabilitation in Heart Failure

Chapter 12 The Patient with Ischemic Heart Failure

Chapter 13 The Non-Ischemic HEART FAILURE Patient

Chapter 14 Valvular Heart Disease and Heart Failure

Chapter 15 The Management of Patients with Heart Failure with Preserved Ejection Fraction (HFpEF)

Chapter 16 Heart Failure with Recovered Ejection Fraction (HFrecEF) and Heart Failure with Midrange Ejection Fraction (HFmrEF)

Chapter 17 The Advanced HEART FAILURE Patient

Chapter 18 Palliative Care and Advanced Directives in Heart Failure

Chapter 10
OUTPATIENT MANAGEMENT OF STABLE HEART FAILURE WITH REDUCED EJECTION FRACTION

Leah Reid, Jonathan Murrow, Kent Nilsson, and Catherine Marti

DOI: 10.1201/9780429244544-13

Introduction

Although therapies for HF with preserved ejection fraction (HFpEF) are lacking, there are many therapies available to patients with HF with reduced ejection fraction (HFrEF), regardless of symptomatology.¹ Careful consideration should be taken at every encounter to evaluate not only volume status but also to optimize guideline-directed medical therapy as well as device therapy. In this chapter, we outline the current therapy available for outpatient management of HFrEF (Table 10.1).

TABLE 10.1: Starting and Target Doses of Select Established and Novel Therapies for Heart Failure

	Starting Dose (mg)	Target Dose (mg)
Beta-Blockers
Bisoprolol	1.25 daily	10 daily
Carvedilol	3.125 b.i.d.	25 b.i.d. for weight <85 kg and 50 b.i.d. for weight ≥85 kg
Metoprolol succinate	12.5–25 daily	200 daily
Angiotensin Receptor Neprilysin Inhibitors
Sacubitril/valsartan	24/26–49/51 b.i.d.	97/103 b.i.d.
Angiotensin-Converting Enzyme Inhibitors
Captopril	6.25 t.i.d.	50 t.i.d.
Enalapril	2.5 b.i.d.	10–20 b.i.d.
Lisinopril	2.5–5.0 daily	20–40 daily
Ramipril	1.25 daily	10 daily
Angiotensin II Receptor Blockers
Candesartan	4–8 daily	32 daily
Losartan	25–50 daily	150 daily
Valsartan	40 b.i.d.	160 b.i.d.
Aldosterone Antagonists
Eplerenone	25 daily	50 daily
Spironolactone	12.5–25 daily	25–50 daily
Sodium-Glucose Cotransporter-2 Inhibitors
Dapagliflozin	10 daily	10 daily
Empagliflozin	10 daily	10 daily
Vasodilators
Hydralazine	25 t.i.d.	75 t.i.d.
Isosorbide dinitrate	20 t.i.d.	40 t.i.d.
Fixed-dose combination isosorbide dinitrate/hydralazine	20/37.5 (1 tab) t.i.d.	2 tabs t.i.d.
Ivabradine
Ivabradine	2.5–5 b.i.d.	Titrate to heart rate 50–60 beats/min. Maximum dose 7.5 b.i.d.
Notes: Isosorbide mononitrate is not recommended by current guidelines, which consider either the fixed-dose combination or the separate combination of isosorbide dinitrate and hydralazine as appropriate guideline-directed therapies for heart failure.
Abbreviations: b.i.d. = bis in die (twice daily); t.i.d. = ter in die (three times daily).
Source: Reproduced with permission from: Maddox et al., J Am Coll Cardiol 2021;77:772–810.

Beta-Blockers

Maladaptive activation of the sympathetic nervous system in HFrEF can lead to worsening congestion, malperfusion, and arrhythmias.² Blockade of β-adrenergic receptors has proven in multiple clinical trials to reduce morbidity and mortality—specifically with metoprolol succinate and bisoprolol, which selectively block β-1-receptors, and with carvedilol, which selectively blocks α-1, β-1 and β-2 receptors.³

In the landmark Cardiac Insufficiency Bisoprolol Study II (CIBIS-II), patients with HFrEF (ejection fraction [EF] ≤35%) and New York Heart Association (NYHA) class II–IV symptoms had a 34% relative risk reduction in all-cause mortality with bisoprolol therapy vs placebo.⁴ The Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure (MERIT-HF) and carvedilol trials likewise demonstrated reduced risk of death or HF hospitalization (Figure 10.1).^5–7 To reduce morbidity and mortality, the 2013 American College of Cardiology/American Heart Association (ACC/AHA) Heart Failure Guidelines thus recommend using either bisoprolol, carvedilol, or sustained-release metoprolol succinate for all patients with current or prior symptoms of HFrEF unless contraindicated (class I, level of evidence [LOE]: A). Importantly, the benefit of β blockers is dose dependent, with lower achieved heart rates associated with improved outcomes, albeit this effect is mostly relevant to patients in sinus rhythm and not among those with atrial fibrillation.⁸ A network meta-analysis of 21 trials found a mortality benefit of β blockers vs p...