Advertisement

Outpatient Medication Titration in Acute Heart Failure

  • Juan R. Vilaro
  • David E. Winchester
Chapter
Part of the Contemporary Cardiology book series (CONCARD)

Abstract

Outpatient management of heart failure has changed significantly over the past 20 years, with evolving concepts of what improves longevity, decreases hospitalizations, and improves functional capacity. Randomized controlled trials have established the efficacy of many medications in reducing morbidity and mortality in patients with heart failure: angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta-blockers (carvedilol, metoprolol succinate, and bisoprolol), aldosterone antagonists, sodium channel blockers, and neprilysin inhibitors. Despite these therapeutic options, patients are frequently undertreated, and appropriate medications are not titrated to evidence-based doses. A stepwise approach to initiation of heart failure medication and titration to therapeutic doses is recommended and can be guided by considering both the American College of Cardiology/American Heart Association (ACC/AHA) class and New York Heart Association (NYHA) functional class of the patient. Such an approach is outlined in this chapter.

Keywords

Blood pressure Nausea Shortness of breath Drug interaction Heart failure Outpatient Defibrillator Medical therapy 

References

  1. 1.
    Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WH, Tsai EJ, Wilkoff BL, Foundation ACoC, Guidelines AHATFoP. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62:e147–239.CrossRefPubMedGoogle Scholar
  2. 2.
    Dolgin M, New York Heart Association, Criteria Committee. Nomenclature and criteria for diagnosis of diseases of the heart and great vessels, vol. xiv. Boston: Little, Brown; 1994. p. 334.Google Scholar
  3. 3.
    Lewis GR. Lisinopril versus placebo in older congestive heart failure patients. Am J Med. 1988;85:48–54.CrossRefPubMedGoogle Scholar
  4. 4.
    Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. The SOLVD Investigators. N Engl J Med. 1991;325:293–302.Google Scholar
  5. 5.
    Acanfora D, Furgi G, Trojano L, Picone C, Iannuzzi GL, Rossi M, Papa A, Rengo C, Rengo F. Quinapril in patients with congestive heart failure: controlled trial versus captopril. Am J Ther. 1997;4:181–8.CrossRefPubMedGoogle Scholar
  6. 6.
    Giles TD, Katz R, Sullivan JM, Wolfson P, Haugland M, Kirlin P, Powers E, Rich S, Hackshaw B, Chiaramida A. Short- and long-acting angiotensin-converting enzyme inhibitors: a randomized trial of lisinopril versus captopril in the treatment of congestive heart failure. The Multicenter Lisinopril-Captopril Congestive Heart Failure Study Group. J Am Coll Cardiol. 1989;13:1240–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. Collaborative Group on ACE Inhibitor Trials. JAMA. 1995;273:1450–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Maggioni AP, Latini R, Carson PE, Singh SN, Barlera S, Glazer R, Masson S, Cerè E, Tognoni G, Cohn JN, Investigators V-H. Valsartan reduces the incidence of atrial fibrillation in patients with heart failure: results from the Valsartan Heart Failure Trial (Val-HeFT). Am Heart J. 2005;149:548–57.CrossRefPubMedGoogle Scholar
  9. 9.
    Granger CB, McMurray JJ, Yusuf S, Held P, Michelson EL, Olofsson B, Ostergren J, Pfeffer MA, Swedberg K, Committees CIa. Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function intolerant to angiotensin-converting-enzyme inhibitors: the CHARM-Alternative trial. Lancet. 2003;362:772–6.CrossRefPubMedGoogle Scholar
  10. 10.
    Poole-Wilson PA, Swedberg K, Cleland JG, Di Lenarda A, Hanrath P, Komajda M, Lubsen J, Lutiger B, Metra M, Remme WJ, Torp-Pedersen C, Scherhag A, Skene A, Investigators COMET. Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): randomised controlled trial. Lancet. 2003;362:7–13.CrossRefPubMedGoogle Scholar
  11. 11.
    Leizorovicz A, Lechat P, Cucherat M, Bugnard F. Bisoprolol for the treatment of chronic heart failure: a meta-analysis on individual data of two placebo-controlled studies--CIBIS and CIBIS II. Cardiac Insufficiency Bisoprolol Study. Am Heart J. 2002;143:301–7.CrossRefPubMedGoogle Scholar
  12. 12.
    The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet. 1999;353:9–13.Google Scholar
  13. 13.
    Wikstrand J, Hjalmarson A, Waagstein F, Fagerberg B, Goldstein S, Kjekshus J, Wedel H, Group M-HS. Dose of metoprolol CR/XL and clinical outcomes in patients with heart failure: analysis of the experience in metoprolol CR/XL randomized intervention trial in chronic heart failure (MERIT-HF). J Am Coll Cardiol. 2002;40:491–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, Palensky J, Wittes J. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med. 1999;341:709–17.CrossRefPubMedGoogle Scholar
  15. 15.
    Pitt B, Williams G, Remme W, Martinez F, Lopez-Sendon J, Zannad F, Neaton J, Roniker B, Hurley S, Burns D, Bittman R, Kleiman J. The EPHESUS trial: eplerenone in patients with heart failure due to systolic dysfunction complicating acute myocardial infarction. Eplerenone Post-AMI Heart Failure Efficacy and Survival Study. Cardiovasc Drugs Ther. 2001;15:79–87.CrossRefPubMedGoogle Scholar
  16. 16.
    Group DI. The effect of digoxin on mortality and morbidity in patients with heart failure. N Engl J Med. 1997;336:525–33.CrossRefGoogle Scholar
  17. 17.
    Packer M, Gheorghiade M, Young JB, Costantini PJ, Adams KF, Cody RJ, Smith LK, Van Voorhees L, Gourley LA, Jolly MK. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-converting-enzyme inhibitors. RADIANCE Study. N Engl J Med. 1993;329:1–7.CrossRefPubMedGoogle Scholar
  18. 18.
    Taylor AL, Ziesche S, Yancy C, Carson P, D’Agostino R, Ferdinand K, Taylor M, Adams K, Sabolinski M, Worcel M, Cohn JN, Investigators A-AHFT. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. N Engl J Med. 2004;351:2049–57.CrossRefPubMedGoogle Scholar
  19. 19.
    Ljungman S, Kjekshus J, Swedberg K. Renal function in severe congestive heart failure during treatment with enalapril (the Cooperative North Scandinavian Enalapril Survival Study [CONSENSUS] Trial). Am J Cardiol. 1992;70:479–87.CrossRefPubMedGoogle Scholar
  20. 20.
    Dicpinigaitis PV. Angiotensin-converting enzyme inhibitor-induced cough: ACCP evidence-based clinical practice guidelines. Chest. 2006;129:169S–73.CrossRefPubMedGoogle Scholar
  21. 21.
    Solomon SD, Appelbaum E, Manning WJ, Verma A, Berglund T, Lukashevich V, Cherif Papst C, Smith BA, Dahlöf B, Investigators ALVHAT. Effect of the direct Renin inhibitor aliskiren, the Angiotensin receptor blocker losartan, or both on left ventricular mass in patients with hypertension and left ventricular hypertrophy. Circulation. 2009;119:530–7.CrossRefPubMedGoogle Scholar
  22. 22.
    Heintz B, Verho M, Brockmeier D, Kirsten R, Nelson K, Rangoonwala B, Maigatter S, Lückel G, Kierdorf H, Sieberth HG. Influence of ramipril on plasma atrial natriuretic peptide, antidiuretic hormone, angiotensin II and aldosterone in patients with chronic congestive heart failure. Clin Physiol Biochem. 1992;9:113–8.PubMedGoogle Scholar
  23. 23.
    Armstrong C, Committee JN. JNC8 guidelines for the management of hypertension in adults. Am Fam Physician. 2014;90:503–4.PubMedGoogle Scholar
  24. 24.
    Packer M, Poole-Wilson PA, Armstrong PW, Cleland JG, Horowitz JD, Massie BM, Rydén L, Thygesen K, Uretsky BF. Comparative effects of low and high doses of the angiotensin-converting enzyme inhibitor, lisinopril, on morbidity and mortality in chronic heart failure. ATLAS Study Group. Circulation. 1999;100:2312–8.CrossRefPubMedGoogle Scholar
  25. 25.
    Bristow MR, Gilbert EM, Abraham WT, Adams KF, Fowler MB, Hershberger RE, Kubo SH, Narahara KA, Ingersoll H, Krueger S, Young S, Shusterman N. Carvedilol produces dose-related improvements in left ventricular function and survival in subjects with chronic heart failure. MOCHA Investigators. Circulation. 1996;94:2807–16.CrossRefPubMedGoogle Scholar
  26. 26.
    Torp-Pedersen C, Metra M, Charlesworth A, Spark P, Lukas MA, Poole-Wilson PA, Swedberg K, Cleland JG, Di Lenarda A, Remme WJ, Scherhag A, COMET investigators. Effects of metoprolol and carvedilol on pre-existing and new onset diabetes in patients with chronic heart failure: data from the Carvedilol Or Metoprolol European Trial (COMET). Heart. 2007;93:968–73.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Louis AA, Turner T, Gretton M, Baksh A, Cleland JG. A systematic review of telemonitoring for the management of heart failure. Eur J Heart Fail. 2003;5:583–90.CrossRefPubMedGoogle Scholar
  28. 28.
    Chaudhry SI, Phillips CO, Stewart SS, Riegel B, Mattera JA, Jerant AF, Krumholz HM. Telemonitoring for patients with chronic heart failure: a systematic review. J Card Fail. 2007;13:56–62.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Shah NB, Der E, Ruggerio C, Heidenreich PA, Massie BM. Prevention of hospitalizations for heart failure with an interactive home monitoring program. Am Heart J. 1998;135:373–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Arcand J, Ivanov J, Sasson A, Floras V, Al-Hesayen A, Azevedo ER, Mak S, Allard JP, Newton GE. A high-sodium diet is associated with acute decompensated heart failure in ambulatory heart failure patients: a prospective follow-up study. Am J Clin Nutr. 2011;93:332–7.CrossRefPubMedGoogle Scholar
  31. 31.
    Chatterjee K. Hyponatremia in heart failure: concluding remarks. Heart Fail Rev. 2009;14:87–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Kollipara UK, Jaffer O, Amin A, Toto KH, Nelson LL, Schneider R, Markham D, Drazner MH. Relation of lack of knowledge about dietary sodium to hospital readmission in patients with heart failure. Am J Cardiol. 2008;102:1212–5.CrossRefPubMedGoogle Scholar
  33. 33.
    O’Connor CM, Abraham WT, Albert NM, Clare R, Gattis Stough W, Gheorghiade M, Greenberg BH, Yancy CW, Young JB, Fonarow GC. Predictors of mortality after discharge in patients hospitalized with heart failure: an analysis from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF). Am Heart J. 2008;156:662–73.CrossRefPubMedGoogle Scholar
  34. 34.
    Anand IS, Rector TS, Kuskowski M, Thomas S, Holwerda NJ, Cohn JN. Effect of baseline and changes in systolic blood pressure over time on the effectiveness of valsartan in the Valsartan Heart Failure Trial. Circ Heart Fail. 2008;1:34–42.CrossRefPubMedGoogle Scholar
  35. 35.
    Loeb HS, Johnson G, Henrick A, Smith R, Wilson J, Cremo R, Cohn JN. Effect of enalapril, hydralazine plus isosorbide dinitrate, and prazosin on hospitalization in patients with chronic congestive heart failure. The V-HeFT VA Cooperative Studies Group. Circulation. 1993;87:VI78–87.PubMedGoogle Scholar
  36. 36.
    Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med. 1995;333:1190–5.CrossRefPubMedGoogle Scholar
  37. 37.
    Philbin EF. Comprehensive multidisciplinary programs for the management of patients with congestive heart failure. J Gen Intern Med. 1999;14:130–5.CrossRefPubMedGoogle Scholar
  38. 38.
    Adams KF, Gheorghiade M, Uretsky BF, Patterson JH, Schwartz TA, Young JB. Clinical benefits of low serum digoxin concentrations in heart failure. J Am Coll Cardiol. 2002;39:946–53.CrossRefPubMedGoogle Scholar
  39. 39.
    Felker GM, O’Connor CM, Braunwald E, Investigators HFCRN. Loop diuretics in acute decompensated heart failure: necessary? Evil? A necessary evil? Circ Heart Fail. 2009;2:56–62.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Chiong JR, Cheung RJ. Loop diuretic therapy in heart failure: the need for solid evidence on a fluid issue. Clin Cardiol. 2010;33:345–52.CrossRefPubMedGoogle Scholar
  41. 41.
    Young JB, Mills RM. Clinical management of heart failure. Caddo: Professional Communications; 2004. 384 p.Google Scholar
  42. 42.
    Vasavada N, Saha C, Agarwal R. A double-blind randomized crossover trial of two loop diuretics in chronic kidney disease. Kidney Int. 2003;64:632–40.CrossRefPubMedGoogle Scholar
  43. 43.
    Moss AJ, Zareba W, Hall WJ, Klein H, Wilber DJ, Cannom DS, Daubert JP, Higgins SL, Brown MW, Andrews ML, Investigators MADITI. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. 2002;346:877–83.CrossRefPubMedGoogle Scholar
  44. 44.
    Cleland JG, Ghosh J, Freemantle N, Kaye GC, Nasir M, Clark AL, Coletta AP. Clinical trials update and cumulative meta-analyses from the American College of Cardiology: WATCH, SCD-HeFT, DINAMIT, CASINO, INSPIRE, STRATUS-US, RIO-Lipids and cardiac resynchronisation therapy in heart failure. Eur J Heart Fail. 2004;6:501–8.CrossRefPubMedGoogle Scholar
  45. 45.
    Bokhari F, Newman D, Greene M, Korley V, Mangat I, Dorian P. Long-term comparison of the implantable cardioverter defibrillator versus amiodarone: eleven-year follow-up of a subset of patients in the Canadian Implantable Defibrillator Study (CIDS). Circulation. 2004;110:112–6.CrossRefPubMedGoogle Scholar
  46. 46.
    Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L, Tavazzi L. Longer-term effects of cardiac resynchronization therapy on mortality in heart failure [the CArdiac REsynchronization-Heart Failure (CARE-HF) trial extension phase]. Eur Heart J. 2006;27:1928–32.CrossRefPubMedGoogle Scholar
  47. 47.
    Bristow MR, Saxon LA, Boehmer J, Krueger S, Kass DA, De Marco T, Carson P, DiCarlo L, DeMets D, White BG, DeVries DW, Feldman AM. Comparison of Medical Therapy Pc, and Defibrillation in Heart Failure (COMPANION) Investigators. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med. 2004;350:2140–50.CrossRefPubMedGoogle Scholar
  48. 48.
    Young JB, Abraham WT, Smith AL, Leon AR, Lieberman R, Wilkoff B, Canby RC, Schroeder JS, Liem LB, Hall S, Wheelan K, Investigators MIIRCEMIT. Combined cardiac resynchronization and implantable cardioversion defibrillation in advanced chronic heart failure: the MIRACLE ICD Trial. JAMA. 2003;289:2685–94.CrossRefPubMedGoogle Scholar
  49. 49.
    Hernandez AF, Hammill BG, O’Connor CM, Schulman KA, Curtis LH, Fonarow GC. Clinical effectiveness of beta-blockers in heart failure: findings from the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) Registry. J Am Coll Cardiol. 2009;53:184–92.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Paulus WJ, Tschöpe C. A novel paradigm for heart failure with preserved ejection fraction: comorbidities drive myocardial dysfunction and remodeling through coronary microvascular endothelial inflammation. J Am Coll Cardiol. 2013;62:263–71.CrossRefPubMedGoogle Scholar
  51. 51.
    Cleland JG, Tendera M, Adamus J, Freemantle N, Polonski L, Taylor J, Investigators P-C. The perindopril in elderly people with chronic heart failure (PEP-CHF) study. Eur Heart J. 2006;27:2338–45.CrossRefPubMedGoogle Scholar
  52. 52.
    Klingbeil AU, Schneider M, Martus P, Messerli FH, Schmieder RE. A meta-analysis of the effects of treatment on left ventricular mass in essential hypertension. Am J Med. 2003;115:41–6.CrossRefPubMedGoogle Scholar
  53. 53.
    Yusuf S, Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, Michelson EL, Olofsson B, Ostergren J, Committees CIa. Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial. Lancet. 2003;362:777–81.CrossRefPubMedGoogle Scholar
  54. 54.
    Massie BM, Carson PE, McMurray JJ, Komajda M, McKelvie R, Zile MR, Anderson S, Donovan M, Iverson E, Staiger C, Ptaszynska A, Investigators I-P. Irbesartan in patients with heart failure and preserved ejection fraction. N Engl J Med. 2008;359:2456–67.CrossRefPubMedGoogle Scholar
  55. 55.
    Hay I, Rich J, Ferber P, Burkhoff D, Maurer MS. Role of impaired myocardial relaxation in the production of elevated left ventricular filling pressure. Am J Physiol Heart Circ Physiol. 2005;288:H1203–8.CrossRefPubMedGoogle Scholar
  56. 56.
    Bergström A, Andersson B, Edner M, Nylander E, Persson H, Dahlström U. Effect of carvedilol on diastolic function in patients with diastolic heart failure and preserved systolic function. Results of the Swedish Doppler-echocardiographic study (SWEDIC). Eur J Heart Fail. 2004;6:453–61.CrossRefPubMedGoogle Scholar
  57. 57.
    Pitt B, Pfeffer MA, Assmann SF, Boineau R, Anand IS, Claggett B, Clausell N, Desai AS, Diaz R, Fleg JL, Gordeev I, Harty B, Heitner JF, Kenwood CT, Lewis EF, O’Meara E, Probstfield JL, Shaburishvili T, Shah SJ, Solomon SD, Sweitzer NK, Yang S, McKinlay SM, Investigators T. Spironolactone for heart failure with preserved ejection fraction. N Engl J Med. 2014;370:1383–92.CrossRefPubMedGoogle Scholar
  58. 58.
    Fox K, Ford I, Steg PG, Tendera M, Ferrari R, Investigators B. Ivabradine for patients with stable coronary artery disease and left-ventricular systolic dysfunction (BEAUTIFUL): a randomised, double-blind, placebo-controlled trial. Lancet. 2008;372:807–16.CrossRefPubMedGoogle Scholar
  59. 59.
    Swedberg K, Komajda M, Böhm M, Borer JS, Ford I, Dubost-Brama A, Lerebours G, Tavazzi L, Investigators S. Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-controlled study. Lancet. 2010;376:875–85.CrossRefPubMedGoogle Scholar
  60. 60.
    McMurray JJ, Packer M, Desai AS, Gong J, Lefkowitz MP, Rizkala AR, Rouleau JL, Shi VC, Solomon SD, Swedberg K, Zile MR, P-HIa C. Angiotensin-neprilysin inhibition versus enalapril in heart failure. N Engl J Med. 2014;371:993–1004.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.Department of Medicine, Division of Cardiovascular MedicineUniversity of FloridaGainesvilleUSA

Personalised recommendations