NEUROHORMONAL
ANTAGONISTS
(1)
ACEI (FDA
approved for heart failure treatment
| ACEI |
Accupril |
Altace |
Capoten |
Mavik |
Monopril |
Prinivil |
Vasotec |
Zestril |
| Generic
name | Quinipril |
Ramipril |
Captopril |
Trandolapril |
Fosinopril |
Lisinopril |
Enalapril |
Lisinopril |
| Starting
Dose | 5
mg bid | 1.25-2.5
mg qd | 6.25-12.5
mg tid | 1
mg qd | 5
mg qd | 2.5-5
mg qd | 2.5
mg bid | 2.5-5
mg qd |
| Target
Dose (a) | 20
mg bid | 10
mg qd | 50
mg tid | 2-4
mg qd | 20
mg qd | 20
mg qd | 10
mg bid | 20
mg qd |
| Maximum
Dose | 40
mg bid | 10
mg bid | 100
mg tid | 8
mg qd | 40
mg qd | 40
mg qd | 20
mg bid | 40
mg qd |
(a) = average maintenance
dose used in clinical trials
(2)
BETA BLOCKER (with Proven Benefit in Heart Failure)
| Beta
Blocker | Action |
Starting
Dose | Target
Dose | FDA
App |
| Carvedilol
(Coreg) (a) | Beta
1; Beta 2, Alpha 1 | 3.125
mg bid | 25
mg bid | Yes |
| Metoprolol
Succinate CR (Toprol XL) | Beta
1 (c) | 12.5
mg qd | 100-200
mg qd | Yes |
| Metoprolol
Tartrate (b) | Beta
1 (c) | 6.25
mg bid | 50-75
mg bid | No |
| Bisoprolol
(Zebeta) | Beta
1 (c) | 1.25
mg qd | 10
mg qd | No |
- There are no proven benefit data for other Beta
blockers.
- (a) = When prescribe low dose, only Carvedilol has proven
benefit. Carvedilol is superior to Metoprolol Tartrate, although dosage may not
be equivalent and there is no comparison to Metoprolol Succinate CR (COMET, 2003)
- (b) = There is no mortality benefit data for Metoprolol tartrate.
- (c) = At target dose in clinical trials, these selective beta blocker
may become non selective ones
(3)
ARB
| ARB |
Initial
Dose | Target
Dose | FDA
approved |
| Losartan
(Cozaar) (1) | 25
mg qd | 50
qd (4) | No |
| Valsartan
(Diovan) (2) | 80
mg qd | 160
mg bid | Yes |
| Irbesartan
(Avapro) | 75
mg qd |
150
- 300 qd (5) |
No |
| Candesartan
(Atacan) (3) | 4
mg qd | 32
mg qd | Yes |
(1) In ELETE II, 2000. (2) In Val-Helf, 2001 and
VALIANT, 2003. (3) In CHARM, 2003, . (4) Dose of 100 mg qd may be
better. (5) Need to be confirmed
(4)
ALDOSTERONE ANTAGONIST (FDA approved for heart failure treatment)| Aldosterone
antagonist | Indication | Initial
dose | Target
dose |
| Spironolactone
(Aldactone) | NYHA
III-IV | 12.5
mg qd | 25
mg qd |
| Eplerenone
(Inspra) | Post
MI with heart fuilure | 25
mg qd | 50
mg qd |
NON
NEUROHORMONAL ANTAGONISTS
. | Initial
dose | Target
dose | Comment |
| Digitalis
(Digoxin) | No
loading dose | 1.25-2.5
mg | . |
| Hydralazine
(1) | 37.5
mg tid | 75
mg tid | Hydralazine
blocks the development of nitrate tolerance. |
| Isosorbide
Dinitrate (2) | 20
mg tid | 40
mg tid | There
is no data on Isosorbide Mononitrate. |
(1)
Hydralazine prevent nitrate tolerance. (2) Nitrate should be used with
Hydralazine. Both should be used at target dose
OTHER
MEDICATIONS IN HEART FAILURE
ASA:
Prefer 81
mg.
Antiarrhythmic Agents: Only Amiodarone and Dofeditilide (Tikosyn)
Calcium
Channel Blockers:
Only Amlodipine.
Medications
Avoid in Heart Failure: NSAIDs,
Cox 2 inhibitors, class I A and IC antiarrhythmic agents (Quinidine, Procainamide,
Flecainide, Propafenone), calcium channel blockers except amlodipine (Norvasc)
and felodipine, corticosteroid, lithium, tricyclic antidepressants, cardiotoxic
agents, glitazones (in heart failure with fluid retention).(See
Diuretics next page)