Page 6 - The 5-Minute Clinical Consult 2021 29th Edition

divided dose
– Metolazone (Zaroxolyn): 2.5 to 20.0 mg/day PO divided dose; hydrochlorothiazide: 12.5 to
100.0 mg/day PO divided dose; chlorothiazide (Diuril): 250 to 2,000 mg/day IV/PO divided
dose
– Spironolactone, eplerenone (improve mortality when added to standard therapy in NYHA
class II to IV + EF <35%): spironolactone 12.5 to 25.0 mg/day PO; maximum 50 mg/day
PO; eplerenone 25 to 50 mg/day; caution regarding hyperkalemia and chronic kidney
disease (CKD)
Digoxin reduces symptoms but has not clearly shown any positive effect on mortality: In
patients with preserved renal function (CrCl >50 mL/min), the recommended dose is 0.125
mg/day. Levels lower than used for atrial fibrillation are effective and safer.
The combination of hydralazine (75 mg/day divided BID or TID) and isosorbide dinitrate (40
mg QID) is effective for improving survival and reducing hospitalizations in African
Americans and can be used if the patient is unable to take an ACE-I or an ARB.
Ivabradine (Corlanor) can be considered in patients with NYHA II and III HF, EF ≤35%, on
maximally tolerated β-blockers with HRs >70 to reduce hospitalization from worsening HF (1)
[B]. Ivabradine is contraindicated in ADHF, hypotension (<90/50 mm Hg), severe hepatic
impairment, pacemaker dependence, bradyarrhythmias, or strong CYP3A4 inhibitors. It
should not be administered to patients who are currently in atrial fibrillation and should be
discontinued if atrial fibrillation develops.
Intravenous iron replacement might improve functional status and quality of life in patients
with NYHA II and III HF and iron deficiency (ferritin <100 ng/mL or 100 to 300 ng/mL if
transferrin saturation <20%).
In diastolic HF, no medical therapy has improved survival. ARBs and spironolactone can be
used to potentially reduce hospitalizations (1)[A].

ADDITIONAL THERAPIES
Device therapy including implantable cardioverter-defibrillators (ICDs) and cardiac
resynchronization therapy (CRT) shown to improve outcomes.
CRT is recommended for patients in sinus rhythm with a QRS width ≥150 ms due to left
bundle branch block (LBBB) and LVEF ≤35% and persistent mild to moderate HF (NYHA II
and III) despite optimal medical therapy. CRT may be considered for ambulatory NYHA class
IV patients in sinus rhythm with a QRS width ≥150 ms, LBBB, and LVEF ≤35% .
CRT may be considered for patients with LVEF ≤35%, sinus rhythm, QRS width ≥150 ms,
non-LBBB pattern, and NYHA III or ambulatory NYHA IV symptoms.
CRT may also be considered for patients with a QRS width between 120 and 150 ms, LBBB,
LVEF ≤35%, and persistent mild to severe HF (NYHA II to IV) despite optimal medical
therapy.
ICDs are recommended for primary prevention in patients with nonischemic CM and ischemic
CM who are at least 40 days post-MI; LVEF ≤35%, NYHA class II or III HF, or LVEF ≤30%,
NYHA I HF; and on optimal medical therapy and >1 year estimated survival; generally not
indicated in American Heart Association (AHA) stage D (end-stage) HF
CRT is recommended in patients with reduced LVEF and chronic RV pacing or with
bradyarrhythmias and an anticipated need for a pacemaker.
Implantable hemodynamic monitoring with devices such as the pulmonary artery pressure
sensor to reduce the risk of admission after an HF-related admission in the last 12 months in
patients with an elevated BNP or NT-proBNP and NYHA functional class III.