Angiotensin Converting Enzyme Inhibitors (ACEI) / Angiotensin Receptor Blockers (ARBS)* Heart Failure Medication Initiation and Titration Bilateral renal artery stenosis NO Moderate/Severe aortic stenosis Considerations: • Baseline cough (ACEi) Hyperkalemia: K+ > 5.2 mmol/L See dosing Symptomatic HF • K+ supplements or LVEF < 40% Renal Dysfunction:Serum creatinine >220 µmol/L • K+ sparing diuretics Hypotension: SBP < 90 mmHg or symptoms YES Refer to • MRA See monitoring Initiation Allergy: angioedema, hives, rash Physician • NSAIDS/COX2 inhibitors section Intolerance: cough (ACEi) Titrate every 1-3 weeks, Volume Reduce/hold diuretic x 2-3 days No improvement, hold/reduce depending on tolerance deplete ACEI/ARB x 1-2 wks & reassess Reassess diuretic dose/other Hypotension Fluid non-essential BP lowering meds Goal: Target dose(see Euvolemic SBP<90mmHg Assessment Consider staggering doses dosing) or maximum with symptoms* Reduce/hold dose of other See Diuretic Reassess Titration * Watch for trends Volume tolerated dose vasodilators algorithm 1-2 wks overload +/- ACEI/ARB x 1-2 weeks Stop K+ supplements, reduce/ Serum K+ in 3-5 days, Considerations: • BP K+ 5.2-5.5 hold MRA (if applicable) Reassess ACEI/ARB dose • Dietary K+ • K+ supplements Stop K+ supplements, MRA. Serum K+ in 2-3 days, • K + Hyperkalemia • K+ sparing diuretics K+ 5.6-6.0 hold ACEI/ARB Reassess ACEI/ARB dose K+ > 5.2 mmol/L* • MRA Assess * Watch for trends • Renal dysfunction Treat hyperkalemia • Scr K+ > 6.0 Refer to MD/NP +/- send to ED Reduce/hold diuretic Scr in Considerations: Volume deplete x 2-3 days 5-7 days • Addition of Renal nephro-toxic drugs: dysfunction Fluid Hold Scr in Rechallenge NSAIDS/COX2 Assessment Euvolemic ACEI/ARB 5-7 days at lower dose >30% in serum • Worsening HF creatinine* • Co-morbidity: DM, Volume Increase diuretic per * Watch for trends dehydration, CKD Diuretic algorithm; Scr in overload reduce/hold of ACEI/ARB 2-3 days Other Considerations: Initiation of Blood Serum Serum ** ACEI/ARB Pressure Creatinine Potassium Angioedema: Cough: • Stop ACEI/ARB contact • Assess at baseline as may be due to One week after: One week after: • Baseline Scr / GFR • Every visit physician; refer to ED worsening HF 1. initiation 1. initiation • Baseline K+ - Siting • Do not rechallenge • If intractable cough secondary to ACEI 2. dosage increase* 2. dosage increase* • Baseline blood pressure - Standing • Caution when substituting consider: 3. > 30% ↑ in Scr - +/- lying ARB for ACEI - Trial of another ACEI or lower dose * Obtain baseline value prior to any - Switch to ARB up-titration or change in symptom status Monitoring • Reassess in 2 weeks and document If stable: Q 3-6 months * This algorithm is intended for single agent (ACEI or ARB) ** This is a guide to monitoring; increase monitoring may be required given patient’s status and co-morbidities (ie. renal insufficiency) December 2018 Beta - Blockers Heart Failure Medication Initiation and Titration Bifascicular block, PR interval prolongation NO (>0.24 msec) Considerations: Bradycardia: HR< 60 bpm or symptomatic • COPD with reversible component • Other rate controlling drugs: See dosing LVEF < 40% 2nd or 3rd degree AV block without a pacemaker - verapamil, diltiazem Hypotension: SBP < 90 mmhg or symptoms - amiodarone YES See monitoring Asthma Refer to - sotalol Initiation - digoxin section Acute decompensated heart failure Physician - ivabradine Intolerance or allergy Reduce/hold diuretic Volume deplete Titrate every 2-4 weeks, Considerations: x 2-3 days depending on tolerance • Other BP lowering drugs: Reassess diuretic dose, No improvement, Goal: Target dose (see Hypotension - vasodilators (nitrates, Euvolemic other BP lowering drugs. hold/reduce BB x SBP<90mmHg hydralazine, CCB) Consider staggering doses 1-2 wks reassess dosing) or maximum - ACEI/ARB/ARNI with symptoms - diuretics Titration tolerated dose Volume overload See below (volume overload) Considerations: Conduction Abnormality: • BP NO Consider decreasing BB dose. • Other rate controlling drugs: • Bifascicular block Reassess in 1-2 weeks • Heart - diltiazem, verapamil • PR interval prolongation Rate Bradycardia - sotalol • 2nd or 3rd degree AV block HR < 55 bpm - amiodarone in the absence of PPM YES Assess with symptoms - digoxin Stop BB • Fluid - Ivabradine Consider referral to Cardiologist Status Considerations: • Maintain BB dose • Other precipitants of fluid Mild symptoms • Increase diuretic retention: • Sodium/fluid restriction - NSAIDS/COX2, glitazones see diuretic algorithm Volume - Salt/fluid intake - Non adherence overload • Consider reducing BB dose - Co-morbidity Moderate to severe symptoms • Increase diuretic - Worsening HF • Sodium/fluid restriction Initiation Fluids/ Blood Pressure Heart Rate Other ** Beta-Blocker Weight Status • Baseline ECG • Every visit • Every visit • Every visit • Extreme limiting fatigue • Baseline heart rate - Siting • ECG as clinically indicated: • Patient should be (other causes ruled out): • Baseline blood pressure - Standing - after each up-titration instructed to perform - could consider decreasing - +/- lying - Δ in symptom status daily weights dose of BB, review in 1-2 weeks Monitoring *verapamil and diltiazem are contraindicated in systolic heart failure (EF < 40%) **This is a guide to monitoring; increase monitoring may be required given patient’s status and co-morbidities December 2018 Mineralocorticoid Receptor Antagonists (MRA) Heart Failure Medication Initiation and Titration Hyperkalemia: K+ > 5.2 mmol/L NO Symptomatic heart Considerations: See dosing failure (NYHA II-IV) Renal Dysfunction:Serum creatinine > 220 • K+supplements µmol/L or a creatinine • K+sparing diuretics on ACEI/ARB or ARNI + clearance < 30 ml/min YES • NSAIDS/COX2 inhibitors Refer to See monitoring BB and LVEF < 40% Physician • ACEI/ARB or ARNI Initiation Intolerance or allergy section Stop K+ supplements, dietitian consult. If no major Serum K+ K+ 5.2-5.5 Titrate monthly depending on Considerations: changes in K+ dietary intake, in 3-5 days tolerance • K+ supplements then reduce/hold MRA • K+ sparing diuretics Goal: Target dose Hyperkalemia • Dietary K+ K+ >5.2 mmol/L Stop K+ supplements, (see dosing below) or • ACEI/ARB or ARNI Hold MRA • Renal dysfunction Titration Serum K+ maximum tolerated dose * Watch for trends K+ >5.5 Reduce/hold ACE/ARB or ARNI Refer to physician/NP in 2-3 days Treat hyperkalemia as required Reduce/hold Volume diuretic x 2-3 Scr in Considerations: deplete days 5-7 days • K+ Renal • Addition of Consider Fluid Reduce/hold Scr in Dysfunction nephrotoxic drugs: Euvolemic re-challenge NSAIDS/COX2 Assessment MRA 5-7 days > 30 % ↑ in SCr at lower dose SCr • ACEI/ARB or ARNI Reduce/hold Assess • * Watch for trends • GI loss Volume MRA Scr in overload Refer to diuretic 2-3 days algorithm Initiation of MRA Serum Creatinine Serum Potassium Other • Baseline Scr / GFR Dosing: ** • Baseline K+ The usual dose is 25 mg daily, however, those with poor renal function and/or a history of hyperkalemia should be initiated on 12.5 mg daily and titrated as tolerated. Some • After initiation: 3 days, 1 week, 4 weeks, then monthly x 3 patients may have their dose increased to 50mg with close monitoring. • Prior to up-titration of MRA • 1 week post up-titration of MRA Other considerations: • With dehydration, illness, change in symptom status or change in Gynecomastia (4-5% of males) with spironolactone. Consider switching to Eplerenone. Monitoring other medications affecting potassium/serum creatinine ** This is a guide to monitoring; increase monitoring may be required given patient’s status and co-morbidities (ie. renal insufficiency) December 2018 ARNI (Angiotensin Receptor blocker / Neprilysin Inhibitors [Sacubutril/Valsartan]) Heart Failure Medication Initiation and Titration Bilateral renal artery stenosis NO Symptomatic HF Considerations: Moderate/Severe aortic stenosis • K+ supplements despite ACEI/ARB • K+ sparing diuretics See dosing and B-blocker Hyperkalemia: K+ > 5.2 mmol/L • MRA therapy Renal Dysfunction:GFR < 30 ml/min • NSAIDS/COX2 inhibitors YES Refer to See monitoring Hypotension: SBP < 90 mmhg or symptoms Physician • Stop ACEI x 36hr prior to start Initiation section • Stop ARB and start following day LVEF < 40% Allergy: angioedema, hives, rash Volume Titrate every 3-6 weeks, Reduce/hold diuretic x 2-3 days No improvement, hold/reduce deplete ARNI x 1-2 wks & reassess depending on tolerance Hypotension Fluid Euvolemic Reassess diuretic dose/vasodilator Goal: Target dose(see SBP<90mmHg Assessment dosing) or maximum with symptoms Reduce/hold dose of other Volume See Diuretic Reassess Titration tolerated dose * Watch for trends vasodilators algorithm 1-2 wks overload +/- ARNI x 1-2 weeks Stop K+ supplements, Serum K+ in 3-5 days, Considerations: • BP K+ 5.2-5.5 reduce/hold MRA Reassess ARNI dose • Dietary K+ • K+ supplements Stop K+ supplements, MRA, Serum K+ in 2-3 days, • K + Hyperkalemia • K+ sparing diuretics K+ 5.6-6.0 hold ARNI Reassess ARNI dose K+ > 5.2 mmol/L • MRA Assess Treat hyperkalemia, * Watch for trends • Renal Dysfunction K+ > 6.0 • Scr Refer to Physician, +/- ED Volume Reduce/hold diuretic Scr in Considerations: deplete x 2-3 days 5-7 days Renal • Addition of nephro- dysfunction toxic drugs (NSAIDS/ Fluid Hold Scr in Rechallenge Euvolemic 5-7 days >30% in serum COX2) Assessment ARNI at lower dose creatinine • Worsening HF • Co-morbidity Volume * Watch for trends Increase diuretic; Scr in overload reduce/hold of ARNI 2-3 days Serum Serum Other Considerations: Initiation ARNI