s1

• First Line Treatment of Heart Failure

  Treatment approaches in heart failure
• Treatment of Chronic Heart Failure: NICE
• If congestive symptoms and fluid retention

  Use loop diuretic
• If risk of thrombosis


  Anticoagulation should be considered
• Avoid: verapamil (blocks cardiac calcium channels)
• Loop diuretics


  furosemide, bumetanide, torasemide
• Loop diuretics


  • Used in pulmonary oedema due to acute left ventricular failure
  • Used in patients with chronic heart failure
  • Adjunct to antihypertensive treatment in resistant hypertension
  • Increase vasodilator effect
  • Intravenous administration provides relief of breathlessness and reduction in pre-load sooner than onset of diuresis
• Loop diuretics


  • Reduce electrolyte reabsorption in thick ascending limb of loop of Henle
  • Promote urinary excretion of Na+, Cl-, K+, H2O
  • Highly potent 'high ceiling' diuretics
  • Oral administration with GI absorption, 50% oral bioavailability
  • Peak effect 30 min, T½ 2 h, Action lasts 4-6 h
  • Rapid onset if I.V. - 10 min
  • Undergoes liver cytochrome P450 metabolism
• Loop diuretics are powerful in that they cause the excretion of 20–25% of filtered Na+
• Loop diuretics vs Thiazide diuretics

  Highly potent 'high ceiling' effect
• Contra-indications for loop diuretics


  • Anuria; drug induced renal failure; severe hypokalaemia; severe hyponatraemia
• Cautions for loop diuretics


  • Risk of urinary retention if an enlarged prostate
  • Risk of hypovolaemia, hypotension, hypokalaemia
  • Hypokalaemia risk reduced by combining with K+ sparing diuretic
  • Use lower dose in elderly
• Side-effects of loop diuretics: Common or very common


  • Dizziness; electrolyte imbalance; fatigue; headache; metabolic alkalosis; muscle spasms; nausea
• HF with reduced cardiac function (ejection fraction <40%): First-line treatment - ACE inhibitor plus beta-blocker
• If symptoms continue

  Use mineralocorticoid receptor antagonists - spironolactone
• Specialist Treatment for HF with reduced ejection fraction


  • Ivabradine
  • Digoxin
  • SGLT2 Inhibitors - Dapagliflozin
  • Sacubitril valsartan
  • Hydralazine with nitrate
• ACE inhibitors


  ramipril, captopril, enalapril, lisinopril and perindopril
• ARBs

  candesartan, losartan, telmisartan and valsartan
• Beta blockers


  • Bisoprolol, carvedilol, nebivolol
  • Inhibits adrenergic beta1 receptors
  • Blocks effects of adrenaline and noradrenaline
  • Inhibits release of renin
  • Slows rate of firing of SAN/AV node - heart rate
  • Negative inotropic effect - cardiac contraction reduced
• Side-effects of beta blockers: dizziness, tiredness, blurred vision
• Most people have either no or very mild side effects that become less troublesome with time
• Treating heart failure with reduced ejection fraction: Beta blockers


  1. Start treatment as 'start low, go slow'

  2. If already taking a beta-blocker for angina or hypertension, switch to a recognised beta blocker used in heart failure
• Beta-blockers are not a preferred initial therapy for hypertension
• Beta-blockers may be considered in younger people for hypertension


  • Intolerance or contraindication to ACE inhibitors and ARB's
  • Women of child-bearing potential
  • Evidence of increased sympathetic drive