Medicines and when should they be prescribed

MEDICINES
INDICATION
Improve Symptoms
Decrease Hosp
Decrease Mortality
ACE Inhibitor - NYHA I - IV.
- Only medicine proved benefit in NYHA I.
-  First medicine to start.
Y
Y
Y
Beta Blocker- NYHA II - IV.
- Do not start in unstable patients.
- Should start early but not before ACEI.
Y
Y
Y
Aldosterone Antagonist - NYHA (III) IV in RALES study (Spironolactone)
- Recent MI with heart failure in EPHESUS study (Eplerenone)
Y
Y
Y
Angiotensin II Receptor Blocker - Substitute for patients that cannot use ACEI.
- Benefit when add to ACEI, beta blocker and aldosterone (CHARM, 2003)
a
a
a
Hydralazine+ISDN - Substitute for patients that cannot use ACEI and ARB.
Y
.
Y
Diuretic - NYHA II - IV
- For symptomatic patients with fluid retention.
Y
Y
b
Digitalis - NYHA II -III (IV)
- For symptomatic patients already on ACEI, beta blocker and diuretic.
Y
Y
.
Antiarrhythmic Agent - Amiodarone, (some) beta blocker, and dofetilide do not have deleterious effect on depressed LV systolic function.
.
.
.
Anticoagulation - No conclusive recommendation for patients with EF <30%.
- Usual indications i.e.., atrial fibrillation, history of systemic emboli.
.
.
.
Calcium Channel Blocker - No indication for heart failure treatment.
- Only amlodipine and felodipine do not have deleterious effect on depressed LV systolic function.
.
.
.
Medicines not recommend- NSAIDs, Cox 2 inhibitors, Class 1A and 1C antiarrhythmic agents , calcium channel blocker except amlodipine and felodipine, glitazones (avandia and actose in Heart failure with fluid retention, cardiotoxic agents.
- Others include coticosteroid, lithium, tricyclic antidepressants.
a = Appears to have similar result and not better than ACEI.
b = Essential for treatment of fluid retention, but no study on mortality to date.

Medicines and when should they be prescribed

NYHA Class
III         III    IV
IV Inotropic..
Digitalis
..1
Diuretic
..
Aldosterone antagonist
.2
Beta blocker
34
ARB
5
ACE Inhibitor
.

1. Digitalis should not be started during this NYHA class.   2. Spironolactone adds to ACEI, Beta blocker (RALES Trial). May prescribe Eplerenone soon after MI with heart failure (EPHESUS Trial).  3. Prescribe after acute MI with or without heart failure symptoms.   4. Add to ACEI. Do not have to wait until reach ACEI target dose.   5a. Prescribe when patient is intolerable or contraindicate to ACEI.   5b. Add to ACEI, Beta blocker. (CHARM, 2003)