How to DOSE medications for systolic heart failure

As a cardiovascular pharmacist, you will be asked more how to dose medications for systolic heart failure. Many cardiac conditions rely on a key "number" to determine drug efficacy. For example, blood pressure guides hypertension treatment and LDL levels guide dyslipidemia therapy. But there's no key number to measure efficacy for heart failure.

Instead, drug therapy is based on controlling symptoms and aiming for "target doses" that show improved survival. The problem is these doses are often higher than those used for hypertension and sometimes hard to tolerate. Suggest starting low and titrating up over a few weeks or months...

ACE inhibitors should be titrated to a target dose of lisinopril (Zestril) 20 to 40 mg/day, enalapril (Ezapril) 10 to 20 mg BID, ramipril (Tritace) 10 mg/day, etc. ARBs are usually saved for patients who can't tolerate ACEIs. Suggest target doses of candesartan (Atacand) 32 mg/day or valsartan (Diovan, Targ) 160 mg twice daily. For ACE inhibitors or ARBs, recommend checking blood pressure (BP), serum potassium, and serum creatinine especially after dosage increases. GET OUR NOTES, "How to safely use ACEIs or ARBs in patients with chronic kidney disease" AND "Expect a serum creatinine bump when starting an ACEI or ARB in kidney disease".

Beta-blockers are used with an ACE inhibitor or ARB. Suggest starting a beta-blocker before reaching the ACE inhibitor's target dose. In fact, adding a beta-blocker to a low-dose ACE inhibitor may improve symptoms more than increasing the ACE inhibitor dose. Aim for carvedilol (Dilatrend) 25 mg BID or up to 50 mg BID for patients over 85 kg, bisoprolol (Concor) 10 mg/day, etc. Monitor heart rate and blood pressure and caution about increasing the dose if resting pulse drops below 60.

If hypotension is a problem, suggest giving the beta-blocker and ACEI at different times, temporarily reducing the ACEI dose or backing off other medications such as diuretics or nitrates. Keep in mind lower target doses of heart failure medications may be needed due to side effects or renal or hepatic impairment.

References

• McMurray JJ. Clinical practice. Systolic heart failure. N Engl J Med. 2010 Jan 21;362(3):228-38. Available at: https://www.nejm.org/doi/full/10.1056/NEJMcp0909392

  McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A; ESC Scientific Document Group. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-3726. Available at: https://academic.oup.com/eurheartj/article/42/36/3599/6358045?login=false