MEDICINEWISE NEWS May 2021 1
MEDICINEWISE
NEWS
May 2021
Up-titrating heart failure medicines –
a practical guide
Key points:
•
People with HFrEF should be prescribed a combination of an ACE inhibitor (or ARB if not tolerated),
a heart failure beta blocker and an MRA, up-titrated to target or maximum tolerated doses, to help
improve quality of life, reduce hospitalisations and save lives.
•
GPs play a vital role in starting and optimising doses of guideline medicines for patients with HFrEF.
•
Up-titration guidance includes: start heart failure medicines at low doses, double the dose one
medicine at a time every 2–4 weeks (except MRAs, up-titrated in 4–8 weeks) and add the next
medicine before reaching target or maximum tolerated dose of the previous medicine.
•
Monitor patients closely with a review 1–2 weeks after each medicine initiation and dose increase, and
make variations to up-titration when required in response to adverse eects.
•
Asymptomatic or mild changes in blood pressure, heart rate or renal function during up-titration do
not usually require dose reduction.
Australian heart failure guidelines are clear on the goal of
pharmacological management for people who have heart
failure with reduced ejection fraction (HFrEF).
That goal is to prescribe a combination of:
1
1. an angiotensin-converting enzyme (ACE) inhibitor, or if
not tolerated, angiotensin receptor blocker (ARB) and
2. a heart failure beta blocker and
3. a mineralocorticoid receptor antagonist (MRA),
all at target or maximum tolerated doses.
The guidelines, developed by the National Heart Foundation
of Australia and the Cardiac Society of Australia and
New Zealand, also describe how to up-titrate these
three medicines to reach the target or maximum
tolerated doses.
1
However GPs can find it challenging to put up-titration
into practice.
2,3
This article provides a practical guide to
assist GPs with the up-titration of heart failure medicines
for people with HFrEF.
Evidence for a combination of heart failure medicines
The recommendation to prescribe a combination of an
ACE inhibitor (or ARB if not tolerated), a heart failure
beta blocker and an MRA at target or maximum tolerated
doses is based on evidence that these medicines together
can help improve quality of life, reduce hospitalisations
and save lives for people with HFrEF.
1,4
What is HFrEF?
HFrEF is defined as left ventricular ejection fraction (LVEF) < 50%, in the presence of symptoms ± signs of heart
failure, where the diagnosis is confirmed with an echocardiogram.
Just under half of people with heart failure have HFrEF. The remaining have preserved ejection fraction (HFpEF).
No medicines have been shown to improve survival for these patients.
1,5
A 2017 meta-analysis found that people with HFrEF who
were prescribed a combination of ACE inhibitor, heart
failure beta blocker and MRA at target doses had a 56%
reduction in all-cause mortality over 1–3 years, compared
to placebo. This combination was much more eective
than an ACE inhibitor or heart failure beta blocker alone, or
a combination of two out of three medicines.
6
See Figure 1.
MEDICINEWISE NEWS May 2021 2
FIGURE 1: Percentage reduction in all-cause mortality over 1–3 years for people with HFrEF on selected, initial heart
failure medicines versus placebo
6
0
10
20
30
40
50
60
heart failure
beta blocker
43%
ACEI + heart
failure beta
blocker
43%
ACEI
+ MRA
43%
ACEI + heart
failure beta
blocker + MRA
56%
ACEI
17%
ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; MRA = mineralocorticoid receptor antagonist
Up-titration guidance
The process of up-titration recommended by Australian
guidelines to reach the goal of a combination of heart
failure medicines is to:
1,4
•
start each medicine at a low dose and
•
gradually up-titrate them to target or maximum
tolerated doses.
See Table 1 for start and target doses.
Start and target doses for heart failure medicines for people with HFrEF
7
CLASS MEDICINE START DOSE TARGET DOSE
ACEI
captopril
enalapril
fosinopril
lisinopril
perindopril arginine
perindopril erbumine
quinapril
ramipril
trandolapril
6.25 mg TDS
2.5 mg D
5 mg D
2.5 mg D
2.5 mg D
2 mg D
5 mg D
2.5 mg BD
0.5 mg D
75 mg BD
20 mg D
40 mg D
50 mg D
10 mg D
8 mg D
20 mg D
5 mg BD
4 mg D
ARB
candesartan
eprosartan
irbesartan
losartan
olmesartan
telmisartan
valsartan
4 mg D
400 mg D
75 mg D
25 mg D
10 mg D
40 mg D
40 mg BD
32 mg D
600 mg D
300 mg D
100 mg D
40 mg D
80 mg D
160 mg BD
Heart failure
beta blocker
bisoprolol
carvedilol
metoprolol succinate MR
nebivolol
1.25 mg D
3.125 mg BD
23.75 mg D
1.25 mg D
10 mg D
50 mg BD
190 mg D
10 mg D
MRA
eplerenone
spironolactone
25 mg D
25 mg D
50 mg D
50 mg D
ARNI
sacubitril/valsartan 49/51 mg BD 97/103 mg BD
HFrEF = heart failure with reduced ejection fraction; ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor
blocker; ARNI = angiotensin receptor neprilysin inhibitor; MRA = mineralocorticoid receptor antagonist; D: daily; BD: twice daily; TDS:
three times a day; MR: modified release
* From the National Heart Foundation of Australia 2018. Clinical factsheet: pharmacological management of chronic heart failure with
reduced left ventricular ejection fraction (HFrEF). Copyright 2019 by National Heart Foundation of Australia. Reprinted with permission.
TABLE 1
MEDICINEWISE NEWS May 2021 3
However rather than a single up-titration pathway
to reach this goal, there are two pathways that are
dierentiated by the patient’s volume status when
starting pharmacological management; euvolaemic
or congested.
1
See Figure 2.
For each pathway, it is recommended to:
•
double the dose of heart failure medicines, one at a
time, every 2–4 weeks (except MRAs; up-titrated in
4–8 weeks), or as tolerated.
1,7,8
•
add the next medicine before reaching target
or maximum tolerated dose, eg, if the patient is
euvolaemic, a heart failure beta blocker may be started
before achieving target or maximum tolerated dose of
an ACE inhibitor.
7
•
review every 1–2 weeks after each medicine initiation
and dose increase, including a clinical review and
checking blood pressure, heart rate, renal function
1,7
In addition, variations during up-titration may be
necessary for patients who experience certain adverse
eects, particularly those that are symptomatic.
1,7
These variations include reducing dosage and pausing
up-titration of a medicine with the aim of reducing or
stopping the adverse eects to enable up-titration to
target dose to be restarted. If adverse eects don’t
improve suciently, the patient may be considered to
have reached maximum tolerated dose.
7
See guidance
on blood pressure Table 2, heart rate Table 3,
renal function Table 4, volume status Table 5, and
miscellaneous Table 6.
Further down the pathways, for people with persistent
HFrEF with left ventricular ejection fraction (LVEF) ≤ 40%,
it’s recommended to change the ACE inhibitor (or ARB) to
an angiotensin receptor-neprilysin inhibitor (ARNI).
1
See Figure 2.
ACE inhibitors, ARBs and ARNIs may be regarded as a
single group of medicines for the purposes of up-titration
and adverse eects.
1
Up-titrate medicines every 2–4 weeks (except MRAs; up-titrated in 4–8 weeks) or
as tolerated. Add next medicine before reaching target or maximum tolerated dose.
Target
dose
or
Maximum
tolerated
dose
Repeat
echocardiogram:
•
after 3–6 months
and/or
•
if change in
clinical status
Change ACEI
(or ARB) to ARNI
if persistent HFrEF with
LVEF ≤ 40% (even if not
already on MRA)
ACEI (or ARB)ACEI (or ARB)
A
C
E
I
(
o
r
A
R
B
)
A
C
E
I
(
o
r
A
R
B
)
Start/titrate/stop loop diuretics (eg, furosemide) only to manage congestion
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HFrEF = heart failure with reduced ejection fraction; ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor
blocker;
ARNI = angiotensin receptor neprilysin inhibitor; MRA = mineralocorticoid receptor antagonist
* Adapted from the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the
prevention, detection, and management of heart failure in Australia 2018. Copyright 2018 by National Heart Foundation of Australia.
Reprinted with permission. https://doi.org/10.1016/j.hlc.2018.06.1042
Adapted from Tomlinson S, Atherton JJ. Heart failure - The crucial role of the GP. Medicine Today 2018; 19:19-27 with permission.
https://medicinetoday.com.au/2018/march/feature-article/heart-failure-crucial-role-gp
FIGURE 2: Initial pharmacological management for people with HFrEF
1,7, 8
MEDICINEWISE NEWS May 2021 4
Up-titration is straightforward for most patients
Professor Ralph Audehm, from the Department of
General Practice and Primary Health Care at Melbourne
University is a Melbourne GP and co-author of the
National Heart Foundation of Australia and the Cardiac
Society of Australia and New Zealand Heart Failure
Guidelines 2018.
‘GPs can be reassured that for the majority of
patients with HFrEF in general practice it is
straightforward to up-titrate to target doses
because they are relatively well, for example,
they have good blood pressure, renal function
and are reasonably active.
These patients usually have no adverse eects
that require a change to the up-titration of
their medicines.
It’s the more frail, usually older patients that
can be more dicult. For them it’s a matter of
picking which medicine to give first for the most
benefit. Then adjusting the medicines in response
to any adverse eects.
You might have smaller dose increases and more
time between each increase. You may also have
to accept they’ll reach maximum tolerated doses
rather than target doses.’
Standard approach and variations that may be required
Professor Andrea Driscoll, from the School of Nursing
and Midwifery at Deakin University, is a Heart Failure
Nurse Practitioner at Austin Health, Melbourne and
co-author of the National Heart Foundation of Australia
and the Cardiac Society of Australia and New Zealand
Heart Failure Guidelines 2018.
‘Years ago the guidance was quite fixed about
up-titrating one medication to maximum dose,
then up-titrate the second one and so forth.
Now it’s realised the combined eect of more
than one medication already started at low doses
and then up-titrating all of them in turn is more
beneficial and this has become the standard
approach.
Most of our patients start with an ACE inhibitor,
then start the heart failure beta blocker, then
increase the ACE inhibitor, then increase the
beta blocker. At some point before reaching
their target doses, we’d start an MRA. Then we’d
up-titrate all three medications in turn until we
reach target doses for each one.
Variations to the above may be required to
address adverse eects, particularly when
they are symptomatic, in response to
their medications.
For example, if the patient is feeling a little bit
more dizzy than normal, I would leave the ACE
inhibitor and up-titrate the beta blocker first. Or
if their heart rate is a little bit too low and they’re
symptomatic, I would leave the beta blocker and
up-titrate the ACE inhibitor.’
GPs and cardiologists working together
GPs can play a vital role with initiating and implementing
up-titration of heart failure medicines. At the same time
patients can benefit from a referral to a cardiologist
specialising in heart failure.
9
‘A shared care approach, where a cardiologist who
specialises in heart failure reviews your patient once a
year, is a good thing,’ says Professor Audehm.
‘We wouldn’t think twice about an annual review for a
patient with, for example, kidney disease. Heart failure has
dreadful mortality and morbidity that we can approach
with the same intent,’ he says.
Indeed, only 50% of people with heart failure are alive
5 years after diagnosis.
7
The all-cause readmission
rate is 20% and all-cause mortality is 8% 30 days after
hospitalisation with heart failure.
10
Once the relationship with a cardiologist is established,
GPs gain access to the cardiologist’s guidance
and management when urgently needed, says
Professor Audehm.
‘You can call the cardiologist if a patient is deteriorating
and ask them to see the patient. You can receive advice,
such as when up-titration is more dicult or challenging,
and this will help build your confidence and skills.’
MEDICINEWISE NEWS May 2021 5
How a GP became confident with up-titration
Sydney GP Dr Peter Piazza took several years to feel comfortable about his patients with heart failure walking
around with a systolic blood pressure of 105 mm Hg.
Dr Piazza belongs to the generation of GPs who were educated never to prescribe beta blockers for heart failure.
Then in the early 2000s he learnt that this guidance had been turned on its head after participating in heart failure
professional education.
The recommendation was to up-titrate heart failure beta blockers, together with ACE inhibitors (or an ARB if the
ACE inhibitor isn’t tolerated) and MRAs to target doses for people with HFrEF. He also learnt that low blood pressure
could be tolerated by these patients.
‘Initially I was nervous about the cardiologist’s advice that patients could go down to a systolic blood pressure of 105.
I thought that was really getting low and was concerned about patients having hypotensive syncope or a fall,’ says
Dr Piazza.
‘I told my patients to let me know straight away if they got any symptoms and I could adjust their dosage. But I found
they tended to stay asymptomatic. Then with more and more patients with that response, my confidence grew,’ he
says.
‘I gradually realised the blood pressure number was less important than the patient’s symptoms and I stopped feeling
nervous.’
And it hasn’t just been for low blood pressure. Dr Piazza has also become confident with his ability to manage
changes in heart rate, renal function and volume status that can occur when up-titrating heart failure medicines.
How to help patients with heart failure medicines
Up-titration can also feel complex for patients who have
to ensure they are correctly taking their medicines and
self-managing their condition.
A patient-centred approach and keeping information
and guidance as simple as possible is recommended
by Professor Driscoll.
At the first visit she always includes guidance on daily
weighing if the patient is congested, an action plan for
when to see the GP again and when to seek emergency
care and an explanation of ‘the bigger picture’ of
their condition.
‘I say to my patients that while you see the cardiologist
every 3 or 6 months, you’ll be seeing me much more
frequently, every 2 to 4 weeks in relation to increasing
the dose of your medications,’ says Professor Driscoll.
‘I explain that if you can increase the dose, your heart will
pump better, you’ll go to the hospital fewer times and
survive longer. But we need to monitor the medicines, we
can’t just put you straight up to the top dose,’ she says.
‘I say this involves us asking lots of questions about any
symptoms, because while there’s no cure for heart failure,
we can improve your symptoms with these medications.’
Patients find this approach helpful and comforting, and it
helps them to achieve the best possible outcomes, says
Professor Driscoll.
MEDICINEWISE NEWS May 2021 6
Blood pressure guidance
Guidance for managing blood pressure adverse eects
Blood pressure (BP) – including orthostatic BP (postural drop):
11,13
Review 1–2 weeks after each medicine
initiation / each medicine dose increase
1,7
ADVERSE EFFECTS ACTIONS
a
ACEI / ARB / ARNI HEART FAILURE BETA
BLOCKER
MRA
Asymptomatic
hypotension
7,11
Continue therapy Continue therapy Continue therapy
Symptomatic hypotension
eg dizziness, light-
headedness and/or
confusion
1,7,11
1. Assess volume status, consider reducing or stopping diuretic
if there are no signs or symptoms of congestion
2. Review other medicines that can reduce blood pressure
(eg calcium channel blockers, nitrates, diuretics)
3. If still symptomatic:
a. temporarily decrease dose of either ACEI/ARB, ARNI or
heart failure beta blocker
b. review patient within 1 week and if still symptomatic
continue dose reduction (or cease) and seek specialist
advice
Continue therapy
Only consider decreasing dose
if, after implementing actions
for ACEI/ARB/ARNI and/
or heart failure beta blocker
to address symptomatic
hypotension, the patient is still
symptomatic.
Severe symptomatic
hypotension / cardiogenic
shock
eg cold and sweaty skin,
dyspnoea, blue skin tone or
weak and rapid pulse
1,11,12
Immediate referral to an emergency department
a
Diuretic dose may be reduced at any time if euvolaemic (unless this has previously exacerbated symptoms)
TABLE 2
Expert advice
•
Hypotension is common because all of the heart
failure medicines tend to lower blood pressure.
•
Most patients only experience 2–3 seconds of
dizziness when they stand up and, if warned (eg stop
and wait for dizziness to subside before start walking),
are safe and tolerate it well.
•
Advice to reduce risk of falls due to dizziness may also
be considered, eg, if experiencing nocturia, turn on
the light when going to the toilet.
•
Symptoms are more important than the actual
number (mm Hg) of the systolic blood pressure.
•
‘I used to get nervous below 110. I’m now
quite comfortable at 100 or even just below.’
Professor Ralph Audehm
•
‘Many of my patients are as low as 90 and
some even 85. But I would stop up-titrating at
85, even if the patient was asymptomatic.’
Professor Andrea Driscoll
•
Measures to help reduce risk of hypotension include:
take medicines at night
avoid dehydration
if dehydrated and taking a diuretic, reduce dosage.
MEDICINEWISE NEWS May 2021 7
Heart rate guidance
Expert advice
•
Symptoms are more important than the actual
heart rate.
•
Symptomatic bradycardia will almost only occur
when the heart rate is < 50 bpm.
•
Symptomatic bradycardia at 50-60 bpm is usually
due to other reasons (eg hypothyroidism, arrythmias)
and should be investigated before considering an
adjustment to the dose of beta blocker.
Professor Andrew Sindone, Director of the Heart Failure
Unit and Department of Cardiac Rehabilitation at
Concord Hospital, Head of Department of Cardiology
at Ryde, co-author of the National Heart Foundation of
Australia and the Cardiac Society of Australia and New
Zealand Heart Failure Guidelines 2018.
•
‘I actively aim for patients to have a heart rate
between 55 and 60. This range is based on
haemodynamic optimisation. You’re trying to
maximise the amount of time the left ventricle
has to fill up before it pumps out.’
•
‘It’s not only about squeezing blood out.
Everyone with heart failure reduced ejection
fraction has a sti ventricle that doesn’t relax
properly. As a result, the heart is not good
at sucking the blood back in. So you want to
maximise the amount of time it has to fill.’
Professor Andrew Sindone
Guidance for managing heart rate adverse eects
Heart rate: Review 1–2 weeks after each medicine initiation / each medicine dose increase
1,7
ADVERSE EFFECTS ACTIONS
a
HEART FAILURE BETA
BLOCKER
ACEI / ARB / ARNI MRA
Asymptomatic bradycardia
(50–60 bpm)
1,14,15
Continue therapy Continue therapy Continue therapy
Symptomatic bradycardia
(< 50 bpm)
eg marked fatigue, dizziness
light-headedness
1,11,14
1. Arrange ECG to document
rhythm
2. Review need for other
medicines that can lower
heart rate (eg digoxin,
amiodarone)
3. If above not successful, may
need to decrease dose and
seek specialist advice
Continue therapy Continue therapy
a
Diuretic dose may be reduced at any time if euvolaemic (unless this has previously exacerbated symptoms)
TABLE 3
MEDICINEWISE NEWS May 2021 8
Renal function guidance
Expert advice
•
Up-titration does not have to stop because of a
change to renal function.
•
While MRAs can lead to hyperkalaemia and ACE
inhibitors can increase serum potassium and
creatinine levels, it is the degree of the change that
determines if actions are recommended.
•
The main challenge is when there are multiple
renal function adverse eects or established renal
impairment.
•
‘If during up-titration of ACE inhibitor, the
eGFR is low, urea and creatinine are high
and the patient is not taking a diuretic,
I recommend reducing the MRA before
considering ACE inhibitor dose reduction.
•
‘Or for patients already with renal impairment
(eg due to kidney disease) we need to decide
what level of poor renal function we’re
prepared to tolerate and maintain low dose
ACE inhibitor, or if the aim is to improve
renal function when the MRA dose is already
reduced, then we’d usually reduce the ACE
inhibitor dose.’
Professor Andrea Driscoll.
•
If unsure how to manage multiple changes to renal
function, consider referral to a cardiologist.
•
A small rise in creatinine is common after starting an
ACE inhibitor; the level will usually return to baseline
after around 4 weeks.
Guidance for managing renal function adverse eects
Renal function: Review 1–2 weeks after each medicine initiation / each medicine dose increase
1,7
RESULTS / ADVERSE
EFFECTS
ACTIONS
a
MRA ACEI / ARB / ARNI HEART FAILURE BETA
BLOCKER
eGFR decrease
≤ 30%
7
Continue therapy Continue therapy Continue therapy
eGFR decrease
> 30%
1,7,11
1. Assess volume status
2. Review need for other medicines that impact on renal
function (eg NSAIDs, diuretics)
3. If above not successful:
Continue therapy
for MRA; decrease dose for ACEI/ARB/ARNI; may
need to:
a. decrease (or stop) dose
b. seek specialist advice
Hyperkalaemia
Serum K+ (potassium)
> 5.5 mmol/L
1,7
1. Assess volume status
2. Review need for other medicines that impact on serum K+
(eg potassium supplements)
3. If above not successful:
Continue therapy
for MRA; decrease dose for ACEI/ARB/ARNI; may
need to:
a. decrease (or stop) dose
b. seek specialist advice
Hyperkalaemia
serum K+ (potassium)
> 6.0 mmol/L
1,7
for MRA, stop and seek
specialist advice
for ACEI/ARB/ARNI follow
above steps 1, 2, 3
Creatinine
increase ≤ 30%
1
Continue therapy Continue therapy Continue therapy
a
Diuretic dose may be reduced at any time if euvolaemic (unless this has previously exacerbated symptoms)
TABLE 4
MEDICINEWISE NEWS May 2021 9
Volume status guidance
Expert advice
•
Use of diuretics shouldn’t be prioritised over the
medicines that decrease mortality; ACE inhibitor/ARB/
ARNI, heart failure beta blocker and MRA.
•
Diuretic dose may be reduced at any time if
euvolaemic (unless this has previously exacerbated
symptoms).
•
When using diuretics to treat congestion, be sure
to use an eective dose eg if there is no response
or inadequate diuresis (weight reduction) the dose
should be doubled (not given BD).
•
‘Diuretics are the Band-Aids of heart failure
management. While they can make a patient
feel better, they’ve never been shown to
improve survival in chronic heart failure and
should only have a limited role.’
Professor Andrew Sindone.
•
‘If the patient is only mildly congested, rather
than using the diuretic to reduce fluid, you
may be able to increase the MRA, which also
helps to increase survival and, compared to
the diuretic, leads to less frequent urination
for the patient.’
Professor Ralph Audehm.
Guidance for managing volume status adverse eects
Volume status: Review 1–2 weeks after each medicine initiation / each medicine dose increase
1,14
ADVERSE EFFECTS ACTIONS
DIURETIC HEART FAILURE
BETA BLOCKER
ACEI / ARB / ARNI MRA
Congestion
(fluid overload, wet)
Signs and symptoms include:
dyspnoea, peripheral/sacral
oedema, increased jugular
venous pressure, weight
gain; ≥ 2 kg over 2 days
1,16,17
If not on a diuretic;
start at low dose
(eg furosemide
20–40 mg daily) and
adjust according to
clinical response
If on a diuretic;
increase dose by
50%–100% with goal
of reducing weight by
0.5–1 kg a day
If weight continues
to increase, seek
specialist advice
If increasing
congestion, consider:
a. decreasing dose,
or
b. temporarily
stopping if
recently started
Continue therapy Continue therapy
Dehydration
(over-diuresis, dry)
Signs and symptoms include:
weight loss; ≥ 2 kg over
2 days, dizziness, thirst,
fatigue, reduced urine
output, increased urine
concentration, orthostatic
BP (postural drop)
1,16,17
If on a diuretic;
decrease dose
(eg furosemide,
reduce by 40 mg)
until weight returns
to baseline
If weight continues
to decrease, seek
specialist advice
Continue therapy
Closely monitor
symptoms
Review renal function
Continue therapy
Closely monitor
symptoms
Review renal function
Continue therapy
Closely monitor
symptoms
Review renal function
TABLE 5
MEDICINEWISE NEWS May 2021 10
Miscellaneous adverse eects guidance
Conclusion
A combination of an ACE inhibitor (or ARB if not
tolerated), a heart failure beta blocker and an MRA
up-titrated to target or maximum tolerated doses,
can help improve quality of life, reduce hospitalisations
and save lives for people with HFrEF.
1,4
However GPs can
find it challenging to put up-titration into practice.
2,3
Following the pathways and guidance described in this
article can make it more straightforward for GPs to up-
titrate heart failure medicines, particularly for the large
group of patients with HFrEF who are relatively well and
who usually do not experience adverse eects requiring
a change to up-titration doses.
Useful resources
For health professionals
Heart Foundation
Clinical fact sheet: pharmacological management of
chronic heart failure with reduced left ventricular ejection
fraction (HFrEF)
Medicine Today
How to optimise therapy for heart failure with reduced
ejection fraction
Largely based on the Guidelines for the Prevention,
Detection, and Management of Heart Failure in Australia
2018, this article is accessible via a subscription or once-
only payment.
For your patients
NPS MedicineWise
Introducing medicines for heart failure
Heart failure: more than just your heart; an action plan for
people with heart failure.
How can I take an active role in managing my heart
failure?
Heart Foundation
Living well with heart failure; this booklet provides
information about what heart failure is, its symptoms,
self-management strategies and pharmacological
management.
Heart failure; this video series provides information about
what is heart failure, pharmacological management,
psychological health and self-management.
Guidance for managing miscellaneous adverse eects
CLINICAL INDICATOR ADVERSE EFFECTS ACTIONS
ACEI / ARB / ARNI HEART FAILURE
BETA BLOCKER
MRA
Respiratory
As part of clinical review
after medicine initiation and
each dose up-titration
Cough
dry, non-productive,
interfering with quality
of life
1
May change ACEI to
ARB
Continue therapy Continue therapy
Allergic reactions
As part of clinical review at
each dose increase
Angioedema
1
Manage the
angioedema, stop
ACEI , ARB or ARNI
and seek specialist
advice
Continue therapy Continue therapy
TABLE 6
nps.org.au
Level 7/418A Elizabeth Street Surry Hills NSW 2010
PO Box 1147 Strawberry Hills NSW 2012
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Disclaimer: Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively
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Find this article online at https://www.nps.org.au/news/up-titrating-heart-failure-medicines
The NPS MedicineWise program on heart failure has been developed
in collaboration with the National Heart Foundation of Australia.