Accessible text and data for figures in MedicineWise News: Up-titrating heart failure medicines: A practical guide

Accessible data and description of the vertical bar graph about heart failure medicines and up-titration algorithm

Figure 1: Percentage reduction in all-cause mortality over 1–3 years for people with HFrEF on selected, initial heart failure medicines versus placebo

Figure 1 is a vertical bar graph. It shows the percentage reduction in all-cause mortality over 1–3 years for people with heart failure with reduced ejection fraction (HFrEF) taking selected, initial heart failure medicines versus placebo.

Heart failure medicines

ACE inhibitor

Heart failure beta blocker

ACE inhibitor
+
heart failure beta blocker

ACE inhibitor
+
MRA

ACE inhibitor
+
heart failure beta blocker
+
MRA

Percentage reduction in all-cause mortality over 1–3 years for people with heart failure with reduced ejection fraction (HFrEF) taking selected, initial heart failure medicines versus placebo

17%

43%

43%

43%

56%

ACE = angiotensin-converting enzyme; MRA = mineralocorticoid receptor antagonist

This data comes from Burnett H, Earley A, Voors AA, et al. Thirty years of evidence on the efficacy of drug treatments for chronic heart failure with reduced ejection fraction: a network meta-analysis. Circ Heart Fail 2017;10:e003529.

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Figure 2: Initial pharmacological management for people with HFrEF

Figure 2 is a flow chart on the initial pharmacological management for people with heart failure with reduced ejection fraction (HFrEF).

Preliminary notes

This flow chart is adapted from two resources.

When a patient has been diagnosed with HFrEF the general guidance for the initial pharmacological management is to up-titrate heart failure medicines every 2–4 weeks (except MRAs, which are up-titrated in 4–8 weeks) or as tolerated. It’s recommended to add the next medicine before reaching target dose or maximum tolerated dose of the medicine that’s already been started.

Two pathways for up-titration

There are two pathways for up-titration, depending on whether:

  • the patient is euvolaemic, or
  • the patient is congested.

Euvolaemic

When the patient is euvolaemic, start with both an ACE (angiotensin-converting enzyme) inhibitor, or ARB (angiotensin receptor blocker) if the ACE inhibitor is not tolerated, and a heart failure beta blocker. Then add later a MRA (mineralocorticoid receptor antagonist). Up-titrate all three medicines to target dose or maximum tolerated dose.

Congested

When the patient is congested, start with an ACE (angiotensin-converting enzyme) inhibitor, or an ARB (angiotensin receptor blocker) if an ACE inhibitor is not tolerated. Then add a MRA (mineralocorticoid receptor antagonist). Once euvolaemic, add a heart failure beta blocker before or after starting the MRA. Up-titrate all three medicines to target dose or maximum tolerated dose.

After reaching target dose or maximum tolerated dose

There are two recommendations after reaching target dose or maximum tolerated dose.

  1. Refer the patient for an echocardiogram 3 to 6 months after reaching target dose or maximum tolerated dose and/or if there is a change in the clinical status of the patient.
  2. If there is persistent HFrEF with reported left ventricular ejection fraction less than or equal to 40% on the echocardiogram, change the ACE inhibitor, or ARB  if the ACE inhibitor is not tolerated, to an ARNI (angiotensin receptor neprilysin inhibitor).

Diuretics

Throughout the whole pharmacological management of HFrEF, start, titrate or stop loop diuretics (eg furosemide) only to manage congestion for the patient.

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