Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX
Initiate guideline-recommended medications for heart failure with reduced ejection fraction (HFrEF)
- Start an ACE inhibitor at a low dose and titrate upwards at short intervals (e.g., every 2 weeks) until the target or maximum tolerated dose is reached NICE CKS.
- Measure serum sodium, potassium, and assess renal function before and 1 to 2 weeks after starting an ACE inhibitor, and after each dose increase NICE CKS.
- Measure blood pressure before and after each dose increase, including in people with symptoms of postural hypotension NICE CKS.
- Once the target or maximum tolerated dose of an ACE inhibitor is reached, monitor treatment monthly for 3 months, then at least every 6 months, and at any time the person becomes acutely unwell NICE NG106.
- If ACE inhibitors are not tolerated, consider an angiotensin-II receptor antagonist (AIIRA), starting at a low dose and titrating similarly, with monitoring of serum electrolytes, renal function, and blood pressure NICE CKS.
- Start a beta-blocker in a 'start low, go slow' manner, assessing heart rate, clinical status, blood pressure, and tolerability after each titration NICE CKS.
- Introduce a mineralocorticoid receptor antagonist (MRA) if symptoms persist despite optimal therapy, with similar monitoring of electrolytes, renal function, and blood pressure NICE CKS.
Seek specialist advice if symptoms persist despite optimized standard care, or if there are contraindications or intolerance to first-line medications NICE CKS.