June 2017
clinical initiatives, research and current updates in treatment
A Bandaid2 for heart failure Sarah Tollemache, Epic Pharmacy Greenslopes Heart failure (HF) is a complex syndrome affecting over 50% of the elderly population.1 Between 20 to 30% of patients with mild to moderate HF and 50% with severe HF die within a year.1 There are two main types of HF, the more common, left ventricular systolic dysfunction (HF‑LVSD), where patients have an ejection fraction of less than 40% and the less common, HF with preserved left ventricular ejection fraction (HFPEF). Treatment of HF-LVSD is focused on delaying disease progression, reducing cardiovascular risk and symptom relief. Standard evidence based guidelines have been developed for the management of HF-LVSD, however adherence to these guidelines is lower than expected. The mnemonic BANDAID2 has been developed to represent evidence based treatment of HF-LVSD and improve guideline adherence.1 BANDAID2
B A N D A I D
Beta-blocker Angiotensin converting enzyme inhibitor / Angiotensin receptor blocker Nitrate and hydralazine Diuretics Aldosterone antagonist Ivabradine Digoxin / devices
Beta-Blocker Beta-blockers are recommended for all patients with HF-LVSD. They have been shown to decrease both the combined risk of death and hospitalisation and the risk of death alone.2 The addition of a
beta-blocker provides greater symptom relief and improvement in both a patient’s clinical status and sense of well-being compared to increasing an ACEI dose.2 Prior to therapy initiation, the patient needs to be hemodynamically stable with minimal evidence of fluid retention as betablockers can exacerbate fluid retention.2 Beta-blockers should be initiated at the lowest possible dose to minimise the risk of common adverse effects such as the worsening of HF, hypotension and bradycardia. The dose can then be doubled at regular intervals of 2 to 4 weeks until a therapeutic dose is achieved.3 Only certain beta-blockers are recommended in the treatment of HF-LVSD and include bisoprolol, carvedilol, nebivolol and controlled release metoprolol.
Angiotensin-converting enzyme inhibitor (ACEI) / Angiotensin receptor blocker (ARB) ACEIs are considered first line therapy in HF-LVSD. They slow disease progression, decrease both the risk of hospitalisation and rate of reinfarction and improve survival.4 In addition, ACEIs have been found to reduce HF-LVSD symptoms, improve physical activity tolerance and quality of life.5 These benefits are seen in patients across all classes of HF-LVSD and there are no differences amongst various ACEIs and their effects on HF-LVSD symptoms and survival.5 If a patient is taking a diuretic prior to starting an ACEI, the diuretic may need to be withheld for 24 hours upon ACEI initiation.3 Certain ARBs (candesartan and valsartan) may be used as an alternative if ACEIs are not tolerated. ARBs have similar benefits to ACEIs, reducing the risk of all-cause mortality and HF-LVSD hospitalisations.6
Hydralazine and Isosorbide Dinitrate (H-ISDN) Hydralazine and isosorbide dinitrate (H-ISDN) complement each other by decreasing afterload and preload respectively.3 In patients already on digoxin and diuretics, high doses of the H-ISDN combination reduces the risk of all-cause mortality, improves exercise capacity and provides symptomatic relief.7 The H-ISDN combination however, has been found to be less effective than ACEIs and there is limited evidence available for combining H-ISDN and ACEIs.8 The H-ISDN combination should be reserved for cases of ACEI/ARB intolerance.8
Diuretics Diuretics, such as frusemide, are recommended in all HF-LVSD patients with fluid overload.2 Whilst diuretics have not been shown to directly prolong survival or alter disease progression, their appropriate use is vital in the success of concomitant medication i.e. beta-blockers.2 Care needs to be taken when initiating diuretics, due to the risk of adverse effects, such as dizziness and electrolyte disturbances. A mild increase in serum creatinine may be observed when diuretics are combined with ACEIs, however, it is not usually an indication to cease the ACEI, but to continue to monitor the patient (weight, electrolytes, kidney function) and adjust the diuretic dose if required.9
Aldosterone antagonist Prescribing an aldosterone antagonist, such as spironolactone, to patients already taking an ACEI, beta-blocker and other diuretics, reduces the risk of all-cause mortality.10 There is also evidence indicating aldosterone antagonists both decrease hospitalisation rates and improve ejection