Heart failure: drug management
A number of drugs have been shown to improve mortality in patients with chronic heart failure:
• ACE inhibitors
• spironolactone
• beta-blockers
• hydralazine with nitrates
No long-term reduction in mortality has been demonstrated for loop diuretics such as furosemide.
NICE issued updated guidelines on management in 2010, key points include:
• first-line treatment for all patients is both an ACE-inhibitor and a beta-blocker
• second-line treatment is now either an aldosterone antagonist, angiotensin II receptor blocker or a hydralazine in combination with a nitrate
• if symptoms persist cardiac resynchronisation therapy or digoxin* should be considered
• diuretics should be given for fluid overload
• offer annual influenza vaccine
• offer one-off** pneumococcal vaccine
*digoxin has also not been proven to reduce mortality in patients with heart failure. It may however improve symptoms due to its inotropic properties. Digoxin is strongly indicated if there is coexistent atrial fibrillation
**adults usually require just one dose but those with asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years