Accessible text and data for figures in MedicineWise News: Up-titrating heart failure medicines: A practical guide
Accessible data and description of the vertical bar graph about heart failure medicines and up-titration algorithm
Figure 1: Percentage reduction in all-cause mortality over 1–3 years for people with HFrEF on selected, initial heart failure medicines versus placebo
Figure 1 is a vertical bar graph. It shows the percentage reduction in all-cause mortality over 1–3 years for people with heart failure with reduced ejection fraction (HFrEF) taking selected, initial heart failure medicines versus placebo.
|
Heart failure medicines |
ACE inhibitor |
Heart failure beta blocker |
ACE inhibitor |
ACE inhibitor |
ACE inhibitor |
|
Percentage reduction in all-cause mortality over 1–3 years for people with heart failure with reduced ejection fraction (HFrEF) taking selected, initial heart failure medicines versus placebo |
17% |
43% |
43% |
43% |
56% |
ACE = angiotensin-converting enzyme; MRA = mineralocorticoid receptor antagonist
This data comes from Burnett H, Earley A, Voors AA, et al. Thirty years of evidence on the efficacy of drug treatments for chronic heart failure with reduced ejection fraction: a network meta-analysis. Circ Heart Fail 2017;10:e003529.
Figure 2: Initial pharmacological management for people with HFrEF
Figure 2 is a flow chart on the initial pharmacological management for people with heart failure with reduced ejection fraction (HFrEF).
Preliminary notes
This flow chart is adapted from two resources.
- National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the prevention, detection, and management of heart failure in Australia 2018. Copyright 2018 by National Heart Foundation of Australia. Reprinted with permission.
- Tomlinson S, Atherton JJ. Heart failure - The crucial role of the GP. Medicine Today 2018; 19:19-27. With permission.
When a patient has been diagnosed with HFrEF the general guidance for the initial pharmacological management is to up-titrate heart failure medicines every 2–4 weeks (except MRAs, which are up-titrated in 4–8 weeks) or as tolerated. It’s recommended to add the next medicine before reaching target dose or maximum tolerated dose of the medicine that’s already been started.
Two pathways for up-titration
There are two pathways for up-titration, depending on whether:
- the patient is euvolaemic, or
- the patient is congested.
Euvolaemic
When the patient is euvolaemic, start with both an ACE (angiotensin-converting enzyme) inhibitor, or ARB (angiotensin receptor blocker) if the ACE inhibitor is not tolerated, and a heart failure beta blocker. Then add later a MRA (mineralocorticoid receptor antagonist). Up-titrate all three medicines to target dose or maximum tolerated dose.
Congested
When the patient is congested, start with an ACE (angiotensin-converting enzyme) inhibitor, or an ARB (angiotensin receptor blocker) if an ACE inhibitor is not tolerated. Then add a MRA (mineralocorticoid receptor antagonist). Once euvolaemic, add a heart failure beta blocker before or after starting the MRA. Up-titrate all three medicines to target dose or maximum tolerated dose.
After reaching target dose or maximum tolerated dose
There are two recommendations after reaching target dose or maximum tolerated dose.
- Refer the patient for an echocardiogram 3 to 6 months after reaching target dose or maximum tolerated dose and/or if there is a change in the clinical status of the patient.
- If there is persistent HFrEF with reported left ventricular ejection fraction less than or equal to 40% on the echocardiogram, change the ACE inhibitor, or ARB if the ACE inhibitor is not tolerated, to an ARNI (angiotensin receptor neprilysin inhibitor).
Diuretics
Throughout the whole pharmacological management of HFrEF, start, titrate or stop loop diuretics (eg furosemide) only to manage congestion for the patient.