Page 5 - The 5-Minute Clinical Consult 2021 29th Edition

factors.
Endomyocardial biopsy should not be performed routinely, only in special circumstances (e.g.,
suspected giant cell myocarditis) that may change therapy.
Test Interpretation
Cardiac pathology depends on underlying etiology.

TREATMENT

GENERAL MEASURES
Correct and treat risk factors for HF. The treatment of chronic HF is focused on improving
hemodynamics, relieving symptoms, and blocking the neurohormonal response to improve
survival.

MEDICATION
Diuretics (for fluid overload) and nitrates (especially for hypertensive patients) are used initially
in acute HF management. The addition of ACE-I and aldosterone antagonists (especially for
HFrEF) can be added at any time. Once acute HF is stabilized, a β-blocker should be started.
Avoid nonsteroidal anti-inflammatory drugs (NSAIDs), which markedly worsen HF. Avoid the
use of diltiazem and verapamil in patients with systolic dysfunction because they may increase
mortality and have negative inotropic effects.

First Line
ACE-I: used to decrease afterload. Shown to increase survival, improve symptoms, and overall
exercise capacity in patients in all NYHA classifications; benefit greatest for patients with
systolic dysfunction and post-MI. Number needed to treat (NNT) ~25 per year for mortality.
All ACE-Is considered equally effective. Initiate at low doses and titrate as tolerated to target
doses.
Angiotensin receptor blockers (ARBs) are indicated for those who are intolerant to ACE-Is. Do
not use combination of ACE-I and ARB.
β-Blockers: used in systolic or diastolic HF (Note: Initiate in hemodynamically
stable/compensated patients at low dose and titrate upward slowly.); NNT = 25/year for
mortality. Mortality decreased in systolic HF; evidence for titration to heart rate (HR) rather
than specific dose
– Carvedilol: 3.125 mg PO BID to a target of 25 mg PO BID; metoprolol succinate extended
release: 12.5 mg/day PO to a target of 200 mg/day PO; or bisoprolol: 1.25 to 10.00 mg once
daily (currently not FDA-approved for the treatment of HF)
Sacubitril/valsartan (Entresto) is an angiotensin receptor blocker and neprilysin inhibitor
(ARNI) shown to reduce the risk of CV death and HF hospitalizations in patients with HFrEF.
In patients with HFrEF and NYHA class II and III symptoms who tolerate an ACE-I or ARB,
and CrCl >30, replacement by an ARNI is recommended to further reduce morbidity and
mortality (NNT to prevent one CV death over 3.5 years: 31). ACE-Is should be discontinued
at least 36 hours prior to starting ARNIs. The most common adverse effects include
hypotension, angioedema, and renal insufficiency. Cost is >$500/month. Diuretics are helpful
to manage volume overload/reduce preload.
– Furosemide (Lasix): 20 to 320 mg/day IV/IM/PO divided dose; bumetanide (Bumex): 0.5
mg to 10.0 mg/day IV/PO divided dose; torsemide (Demadex): 10 to 200 mg/day PO