SOME IMPORTANT POINTS TO REMEMBER:

TREATMENT OF SYSTOLIC HEART FAILURE:

1) In patients with systolic Heart Failure, Beta blockers(BB) should be started after the fluid
retention has been treated.
2) Systolic Heart Failure (symptomatic) USE BB, ACEI/ARB, Spironolactone/Eplerenone.
3) Digoxin is also indicated in patients with both systolic failure and chronic atrial fibrillation.
4) Addition of a fixed-dose combination of hydralazine/isosorbide dinitrate to an ACE inhibitor and
beta blocker is recommended in African-American patients with NYHA class IIIV heart failure.
5) Device therapy should be considered in addition to drug therapy in appropriate patients, as
indicated. Primary prevention- LVEF less than 35% on medical therapy
6) Signs of Edema or Fluid overload treated with LOOP DIURETICS ( Furosemide, torsemide,
bumetamide), Not thiazide as first line.
7) DRUGS THAT IMPROVE SURVIVAL/ cause REVERSE REMODELING ( IMPROVEMENT IN LVEF AND
DECREASE IN LV SIZE
- Beta Blockers ( carvedilol, metoprolol succinate, bisoprolol)
- ACE Inhibitors/ Angiotensin receptor blockers ( enalapril/ Losartan etc)
- Aldosterone antagonist ( Spironolactone, Eplerenone)
- Hydralazine/ISDN in selected patients African American

8) DRUGS THAT DO NOT IMPROVE SURVIVAL in patients with systolic HF: Digoxin, Diuretics
9) Drug that reduced HF hospitalization when added to medical therapy Digoxin
10) DRUGS THAT INCREASE MORTALITY/DECREASE SURVIVAL inotropes dobutamine and
milrinone.
11) DRUGS THAT SHOULD NOT BE USED IN PATIENTS WITH Systolic CHF: NSAIDS, Class I
antiarrhythmics, Calcium channel Blockers (verapamil, diltiazem)
12) VASODILATORS TO BE USED INPATIENT SETTING e.g acute decompensated state, acute
pulmonary edema: Nitroprusside, Nitroglycerin
13) COMMONLY USED INOTROPES in SYSTOLIC HF: Dobutamine, milrinone, dopamine,
norepinephrine.
14) Dobutamine Beta 1 agonist increase in contractility
15) Milrinone: PDE 3 inhibitor: increases contractility, vasodilation.
16) Nesiritide: used for treatment of dyspnea from CHF, also a vasodilator, recombinant BNP, used
IV, NOT RECOMMENDED FOR ROUTINE USE.
17) Drugs used in HF which are contraindicated in pregnancy: ACE inhibitors, ARB, Spironolactone,
Eplerenone.
 FEW IMPORTANT SIDE EFFECTS OF DRUGS USED TO TREAT HEART FAILURE: ( this is not
comprehensive list of side effects, please refer to your textbooks for entire list)

1) ACE INHIBITORS: angioedema, cough, hyperkalemia, Contraindicated bilateral renal artery

stenosis, pregnancy
2) Beta Blockers: Bradycardia, bronchospasm; Contraindications- cardiogenic shock, severe
bronchospasm, 2nd and 3rd degree AV block
3) Spironolactone: Hyperkalemia, Gynecomastia, DO NOT USE if Cr > 2.0 -> increases risk of
hyperkalemia
4) Furosemide: Hypokalemia, ototoxicity
5) Digoxin: remember to monitor levels, narrow therapeutic index. Consider use in HF + AFIB,
Common side effects: nausea, vomiting, anorexia, fatigue, yellow vision, Arrhythmia- AV
Block, Ventricular arrhythmia. Watch for drug-drug interactions, Hypokalemia increases
risk of toxicity.
6) Hydralazine: Drug induced Lupus
7) Nitrates: venodilation, headaches.
8) Nitroprusside: Cyanide toxicity
9) Nesiritide: vasodilation, hypotension
10) Dobutamine, Milrinone: can cause tachyarrhythmias

TREATMENT OF DIASTOLIC HEART FAILURE:

- Treat volume overload with diuretics

- Treat Hypertension with current guidelines
- Treat coronary artery disease per current guidelines
- Treat arrhythmias per guidelines
- NO PROVEN DRUG TO IMPROVE SURVIVAL

TREATMENT OF ACUTE PULMONARY EDEMA:

- remember LMNOP Lasix, Morphine, Nitrates, Oxygen, Position

ABBREVIATIONS USED:

BB: beta blocker

ACEI: Angiotensin converting enzyme inhibitor

ARB: Angiotensin receptor blocker

Cr: Creatinine

HF: heart failure

LVEF: Left ventricular ejection fraction

NYHA: new York heart association classification of functional capacity.