Medical Therapy Guidance
| NYHA CLASS | PRESCRIBE |
|---|---|
| Step 1: NYHA I-IV | ACE BetaBlocker |
| Step 2: Still NYHA II-IV and EF≤35% despite Step 1 | Add Spironolactone or Eplerenone (specialist advice) |
| Step 3: Still NYHA II-IV, EF≤35%, SR and heart rate ≥70bpm despite Steps 1 and 2 | Add Ivabradine (specialist advice) |
The above medications can be given in conjunction with a loop diuretic if indicated. Although there is no evidence for diuretics, they do improve symptoms.
LVSD diagnosed → Commence diuretic (if fluid retention present) / Initiate and titrate up: ACE inhibiter + Beta Blocker + Aldosterone Antagonist / Consider ARB only if intolerant of ACEi → Atrial Fibrillation → Warfarin (or other OAC) & Digoxin (low dose preferred)
LVSD diagnosed → Commence diuretic (if fluid retention present) / Initiate and titrate up: ACE inhibiter + Beta Blocker + Aldosterone Antagonist / Consider ARB only if intolerant of ACEi → Sinus Rhythm (Target HR 55-60bpm) → Add Ivabradine if: intolerant of Beta Blockers or Maximum possible BB dose reached and in Sinus Rhythm with HR > 75bpm
Pulse point
Refer to local guidelines and formulary for practical advice.
You may find it useful to review modules 3, 4 and 5 to learn more about these drugs and their actions. It is important that when considering your patient’s cardiac medication regime you familiarise yourself with the different actions and interactions of these drugs in the context of your individual patient. Find more information at:
- SIGN 147
- ESC Guidelines (2012)
- British National Formulary – this requires you to create an account but is free access.
Page last reviewed: 28 Jul 2020
