However rather than a single up-titration pathway to reach this goal, there are two pathways that are differentiated by the patient’s volume status when starting pharmacological management; euvolaemic or congested.1
See Figure 2.
For each pathway, it’s recommended to:
- double the dose of heart failure medicines, one at a time, every 2–4 weeks (except MRAs; up-titrated in 4–8 weeks), or as tolerated.1,7,8
- add the next medicine before reaching target or maximum tolerated dose, eg, if the patient is euvolaemic, a heart failure beta blocker may be started before achieving target or maximum tolerated dose of an ACE inhibitor.7
- review every 1–2 weeks after each medicine initiation and dose increase, including a clinical review and checking blood pressure, heart rate, renal function.1,7
In addition, variations during up-titration may be necessary for patients who experience certain adverse effects, particularly those that are symptomatic.1,7
These variations include reducing dosage and pausing up-titration of a medicine with the aim of reducing or stopping the adverse effects to enable up-titration to target dose to be restarted. If adverse effects don’t improve sufficiently, the patient may be considered to have reached maximum tolerated dose.7
See guidance on blood pressure Table 2, heart rate Table 3, renal function Table 4. volume status Table 5, and miscellaneous Table 6.
Further down the pathways, for people with persistent HFrEF with left ventricular ejection fraction (LVEF) ≤ 40%, it’s recommended to change the ACE inhibitor (or ARB) to an angiotensin receptor-neprilysin inhibitor (ARNI).1
See Figure 2.
ACE inhibitors, ARBs and ARNIs may be regarded as a single group of medicines for the purposes of up-titration and adverse effects.1