l6

• Heart failure with reduced cardiac function (ejection fraction <40%)

  First-line treatment - ACE inhibitor plus beta-blocker
• If symptoms continue


  1. Mineralocorticoid receptor antagonists – spironolactone

  2. Specialist Treatment:

  3. Ivabradine

  4. Digoxin

  5. SGLT2 Inhibitors - Dapagliflozin

  6. Sacubitril valsartan

  7. Hydralazine with nitrate
• Spironolactone


  Aldosterone antagonist, improves survival in chronic heart failure (RALES study), contraindicated if hyperkalaemia or renal impairment, anti-hypertensive in patients with resistant hypertension
• Spironolactone


  • Steroid pro-drug, effects via active metabolite canrenone, half-life 10 min, canrenone half-life 9-16 h, blocks aldosterone-induced production of sodium transport proteins in the DCT, causes Na+ & H2O loss, K+ retention
• 1. sparing diuretics


  Inhibit the action of aldosterone on the collecting ducts, weak diuretics but important for the sparing of K, often used in conjunction with Loop or Thiazide diuretics
• Ivabradine


  Inhibits If current reducing cardiac pacemaker activity, slows heart rate, alternative to beta blockers (may be used alongside)
• Contra-indications for Ivabradine - MI, cardiogenic shock, heart block, slow heart rates
• Cautions for Ivabradine - ineffective if atrial fibrillation present, elderly, angina
• Common or very common side effects of Ivabradine - arrhythmias; AV block; dizziness; headache
• Sacubitril valsartan


  Combination of an ARB and Sacubitril, Sacubitril (prodrug) inhibits the breakdown of natriuretic peptides, increased diuresis, natriuresis and vasodilation, may be used in patients not currently taking an ACE inhibitor or ARB
• Contra-indications for Sacubitril valsartan - Systolic blood pressure <100 mmHg
• Common or very common side effects of Sacubitril valsartan - anaemia; cough; diarrhoea; dizziness; electrolyte imbalance; headache; hypoglycaemia; hypotension; nausea; renal impairment; syncope; vertigo
• Hydralazine with nitrate


  For patients intolerant of both ACE inhibitors and ARBs (African-African Caribbean origin), moderate to severe heart failure, venodilators reduce pre-load and reduce the risk of pulmonary congestion, arterial vasodilators reduce after-load and increase stroke volume
• Contra-indications for Hydralazine with nitrate - acute porphyrias; cor pulmonale; dissecting aortic aneurysm; poor cardiac function due to mechanical obstruction; tachycardia
• Common or very common side-effects of Hydralazine with nitrate - angina, headaches, tachycardia, diarrhoea; dizziness; flushing; gastrointestinal disorders; headache; hypotension; joint disorders; lupus-like syndrome
• Cautions for Hydralazine with nitrate - cerebrovascular or coronary artery disease
• Digoxin


  Antiarrhythmic drug that increases vagal tone to heart, positive inotrope that increases intracellular Ca, indications for use - chronic heart failure (improves symptoms but not mortality rates), supraventricular arrhythmias, chronic atrial fibrillation
• Digoxin


  • Oral administration bioavailability ~75%, onset of action ~30 min, peak effect (IV) 1-5 h, half-life 36 h, elimination ~70% renal, GFR, VD 640L / 70kg, binds to skeletal muscle, narrow therapeutic range, risk of toxicity
• Contra-indications for Digoxin - heart block
• Cautions for Digoxin - risk of digitalis toxicity with electrolyte imbalances, recent MI
• Common or very common side-effects of Digoxin - arrhythmias; cardiac conduction problems; cerebral impairment; diarrhoea; dizziness; nausea; skin reactions; vision disorders; vomiting
• SGLT2 Inhibitors - Dapagliflozin


  Blocks the SGLT2 glucose transporter in the renal PCT, glycosuria and fluid loss, haemodynamic changes reduce pre-load and after-load, cardiac function improves
• Adverse effects of SGLT2 Inhibitors - rare severe ketoacidosis
• Contra-indications for SGLT2 Inhibitors - diabetic ketoacidosis
• Cautions for SGLT2 Inhibitors - elderly; hypotension; risk of volume depletion