Clinical Pharmacology · MU Sofia

27. Rational drug prescribing in patients with chronic heart failure.

Covers prescribing for chronic heart failure by ejection fraction band, starting with the four drug classes that reduce mortality in reduced ejection fraction, with a table giving examples and monitoring cautions for each. It then notes symptom-relief and other treatments, drug choices for mildly reduced and preserved fraction, drugs to avoid, and a brief outline of acute heart failure management.

Inside: 5 sections · 1 table · 15 flashcards · 2 min

Topic 27 of 30 in the MU Sofia syllabus for Clinical Pharmacology (Medicine, Year 5). The free AceMed note covers it in 5 sections, about 213 words (2 min of reading), with 15 flashcards.

In this note

  1. Introduction
  2. HFrEF: the four pillars (ESC 2021/2023)
  3. HFmrEF and HFpEF
  4. Drugs to avoid in HF
  5. Acute heart failure

Introduction

Heart failure (HF) is a syndrome of symptoms (breathlessness, fatigue, oedema) caused by a structural or functional heart abnormality. Drug choice depends on the ejection fraction (EF): reduced (HFrEF ≤ 40%), mildly reduced (HFmrEF 41–49%) or preserved (HFpEF ≥ 50%).

HFrEF: the four pillars (ESC 2021/2023)

Four drug classes each reduce mortality and hospitalisation, and all four should be started early, within weeks, and titrated to target doses:

Symptom relief and other treatment

  • Loop diuretics (furosemide) relieve congestion and oedema but do not improve survival: use the lowest dose that keeps the patient "dry".
  • Ivabradine (sinus rhythm, heart rate ≥ 70 despite β-blocker), hydralazine + isosorbide dinitrate, digoxin (AF, symptoms), IV iron for iron deficiency, vericiguat.
  • Devices: ICD (EF ≤ 35%), CRT (wide QRS).
  • Treat the cause: ischaemia, hypertension, valves, arrhythmias; vaccinate against influenza and pneumococcus; salt and fluid advice, exercise rehabilitation.

HFmrEF and HFpEF

  • SGLT2 inhibitors reduce hospitalisation; diuretics for congestion.
  • Treat co-morbidities: hypertension, AF, diabetes, obesity, coronary disease.

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