=====Heart Failure=====
====HFrEF====
Goal of Heart Failure Mx - to prescribe combination of all at low initial doses and titrate to target/max tolerated doses (//with doubling of doses//), one at a time :
<accordion autoclose>
<accordion-item title="euvolaemic">
  -an angiotensin-converting enzyme (ACE) inhibitor, or if not tolerated, angiotensin receptor blocker (ARB)  **and**\\ 
  -a heart failure beta blocker **then add**\\ 
  -a mineralocorticoid receptor antagonist (MRA)

</accordion-item>
<accordion-item title="hypervolaemic">
  -an angiotensin-converting enzyme (ACE) inhibitor, or if not tolerated, angiotensin receptor blocker (ARB)  **and**\\ 
  -a mineralocorticoid receptor antagonist (MRA) then **when euvolaemic, add**\\ 
  -a heart failure beta blocker
</accordion-item>
</accordion>
^<wrap em>ACEi\\ Angiotensin-converting enzyme inhibitors</wrap> ^initial ^target |
^enalapril |2.5mg OD |20mg OD |
^lisinopril |2.5mg OD |50mg OD |
^perindopril |2.5mg OD |10mg OD |
^ramipril |2.5mg bd |5mg bd |
^<wrap em>ARB\\ Angiotensin receptor blockers</wrap> ^initial ^target |
^candesartan |4mg OD |32mg OD |
^irbesartan |75mg OD |300mg OD |
^losartan |25mg OD |100mg OD |
^valsartan |40mg bd |160mg bd |
^olmesartan |10mg OD |40mg OD |
^<wrap em>β blockers</wrap> ^initial ^target |
^bisoprolol |1.25mg OD |10mg OD |
^carvedilol |3.125mg bd |50mg bd |
^nebivolol |1.25mg OD |10mg OD |
^<wrap em>MRA\\ Mineralocorticoid receptor antagonists</wrap> ^initial ^target |
^spironolactone |25mg OD |50mg OD |
^eplerenone |25mg OD |50mg OD |
^<wrap em>ARNI\\ angiotensin receptor/neprilysin inhibitor</wrap> ^initial ^target |
^sacubitril/valsartan |49/51 mg bd |97/103 mg bd |
^<wrap em>other</wrap> ^initial ^target |
^ivabradine |5mg bd |7.5mg bd |
 **STRATEGY: **\\ 
  *double the dose of each, one at a time, every 2–4/52(except MRAs; up-titrated in 4–8/52), or as tolerated.
  *add the next drug before reaching target or maximum tolerated dose, eg, if the patient is euvolaemic, a heart failure beta blocker may be started before achieving target or maximum tolerated dose of an ACE inhibitor.
  *clinical and lab review every 1–2/52 after each medicine initiation and dose increase,

**If symptoms persist, consider:**
  -add hydralazine and nitrate (esp if Afro-Caribbean)
  -digoxin for those is sinus
  -for LVEF ≤ 35%, change ACE inhibitor (or ARB) to an angiotensin receptor-neprilysin inhibitor (ARNI).
  -for LVEF ≤ 35%, add ivabradine for sinus HR>75
==== Heart failure with preserved ejection fraction (HFpEF)====
  *Clinical syndrome of  signs and symptoms of HF as the result of high LV filling pressure despite normal or near normal LV ejection fraction (LVEF; ?50 percent). Most have normal LV volumes and an abnormal diastolic filling pattern.
  * There is no clear evidence that pharmacologic therapy, diet, or other therapies reduce the risk of mortality in patients with HFpEF
   *Condition commonly associated with HFpEF conditions are managed using approaches similar to those used to treat the general population or other forms of HF; there is no evidence for HFpEF-specific management of these conditions, including:
    *HTN, atrial fibrillation (AF), coronary artery disease
    *hyperlipidemia, obesity, anemia, diabetes mellitus, chronic kidney disease (CKD), and sleep-disordered breathing
==Management strategy==
  *for those with HF & elevated pro-BNP – SGLT2 inhibitor 1st and, if tolerated, add MRA after 2/52 later
==References include:==
[[https://pro.boehringer-ingelheim.com/us/focusonhfpef/#:~:text=HFpEF%20is%20typically%20defined%20as,HFrEF%20goes%20beyond%20ejection%20fraction.|HFrEF vs HFpEF]]\\ 

^LOOP DIURETIC CONVERSION CHART ||
^Loop diuretics ^Oral ^IV |
^Furosemide (Lasix) |40mg |20mg |
^Bumetanide (Bumex) |1mg |1mg |
^ Torsemide |10-20mg |10-20mg |

[[https://kidneyfoundation.cachefly.net/professionals/KDOQI/guidelines_bp/guide_12.htm|diuretics in CKD]]
=====Heart Failure=====
{{:wiki:cardiovascular:chronic_heart_failure_mx.png?500|}}

[[https://www.aafp.org/pubs/afp/issues/2017/1101/p582.html|Dx and Mx of HFpEF]]\\ 
[[https://www.uptodate.com/contents/treatment-and-prognosis-of-heart-failure-with-preserved-ejection-fraction/print#:~:text=INTRODUCTION%20Heart%20failure%20with%20preserved,)%20%5B1%2D5%5D.]]\\ 
[[https://www.nps.org.au/news/up-titrating-heart-failure-medicines]]\\ 
[[https://www.heartlungcirc.org/article/S1443-9506(18)31777-3/fulltext]]\\ 
<card header="SC furosemide">
[[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6059009/|SC furosemide in HF]]\\ [[https://www.heartfailurehubscotland.co.uk/wp-content/uploads/2016/04/NHS-Highlands-SC-furosemide-policy3.pdf|WestMidlands review]]\\ 
Trusts using:\\ [[https://www.bsuh.nhs.uk/library/wp-content/uploads/sites/8/2021/08/subcutaneous-furosemide-in-end-stage-heart-failure-final-August-2021.pdf|Brighton]]\\ [[https://www.yorkandscarboroughformulary.nhs.uk/docs/BNF/02/Guidelines%20for%20subcutaneous%20Furosemide%20in%20the%20community.pdf|York]]\\ [[https://medicinesmanagement.doncasterccg.nhs.uk/wp-content/uploads/2022/05/Guidance-for-the-Prescribing-of-Subcutaneous-Furosemide-by-Bolus-or-Syringe-Driver-for-Heart-Failure.pdf|Doncaster]]\\ [[https://www.heartfailurehubscotland.co.uk/wp-content/uploads/2016/04/NHS-Highlands-SC-furosemide-policy3.pdf|Scottish Highlands]]\\ 

Reliability:
[[https://www.jhoponline.com/issue-archive/2022-issues/march-2022-vol-12-special-feature/19318-evaluation-of-the-reliability-of-5-fu-elastomeric-pump-in-an-ambulatory-infusion-center]]\\ [[https://academic.oup.com/jac/article/73/9/2540/5049033|the pumps for IV antibiotics]]\\ [[https://www.sciencedirect.com/science/article/pii/S0399077X20307599|review elastomeric pumps, antibiotics]]\\ 
</card>