Both an ACE inhibitor (ramipril or lisinopril) and beta-blocker (bisoprolol or carvedilol) should be started as soon as possible after diagnosis:

• ACE inhibitor: titrate upwards at short intervals (e.g. every 2 weeks) until the optimal tolerated or target dose is achieved
  • Ramipril start 2.5mg daily - target dose 5mg twice daily or 10mg daily
  • Lisinopril start 2.5-5mg daily - target dose 20-35mg once daily
  • Perindopril erbumine start 2mg once daily - target dose 4mg once daily
• If ACE inhibitor not tolerated (e.g. due to cough) consider angiotensin II receptor antagonists (A2RB): candesartan or losartan.
  • Candesartan start 4-8mg once daily - target dose 32mg once daily
  • Losartan start 50mg once daily - target dose 150mg once daily
  • Valsartan start 40mg twice daily - target dose 160mg twice daily
• Beta-blocker: titrate upwards to target or maximum tolerated dose
  • Bisoprolol
    • Initially 1.25mg once daily for one week
    • If well tolerated - increase to 2.5mg once daily for one week
    • Then 3.75mg once daily for one week
    • Then 5mg once daily for four weeks
    • Then 7.5mg once daily for four weeks
    • Then 10mg once daily - target dose
  • Carvedilol
    • Initially 3.125mg twice daily (with food)
    • Dose increased at intervals of at least two weeks to 6.25mg twice daily
    • Then to 12.5mg twice daily
    • Then to 25mg twice daily
    • Increase to highest dose tolerated, maximum 25mg twice daily in patients less than 85kg body-weight and 50mg twice daily in patients over 85kg
    • Target dose: 25-50mg twice daily

Consider a loop diuretic to relieve symptoms of congestion and fluid retention

Offer rehabilitation and education

Notes

1. A diuretic is first-line therapy when a patient presents with acute pulmonary oedema.

If symptoms persist despite optimal first-line therapy, seek specialist advice and consider adding one of the following second-line treatments:

• Torbay Hospital & Community Integrated Heart Failure Team Monday to Friday 9-4pm 01803 655178
• Plymouth Community Heart Failure Nurse Specialists 01752 434521
• Aldosterone antagonists (spironolactone or eplerenone) - titrate upwards to target or maximum tolerated dose. Seek specialist advice if hyperkalaemia develops or renal function deteriorates.
  • Spironolactone start 25mg once daily - target dose 25-50mg once daily
  • Eplerenone 25mg once daily - target dose 50mg once daily
• An A2RB licensed for heart failure (candesartan is licensed for use in combination with ACE inhibitors, losartan is not)
• Ivabradine in combination with standard therapy (beta-blocker/ACE inhibitor/aldosterone antagonist) or as an alternative to beta-blockers in the following patient groups:
  • with New York Heart Association (NYHA) class II to IV stable chronic heart failure with systolic dysfunction and
  • who are in sinus rhythm with a heart rate of >75 beats per minute (bpm) and
  • who have a left ventricular ejection fraction of 35% or less
• Hydralazine may be used in combination with nitrate (especially in patients of African or Caribbean origin with moderate to severe heart failure or in any patients with Class III and IV who are unable to take an ACE or A2RB)
• Dapagliflozin and empagliflozin as an add-on to optimised standard care with:
  • angiotensin-converting enzyme (ACE) inhibitors or angiotensin-2 receptor blockers (ARBs), with beta blockers, and, if tolerated, mineralocorticoid receptor antagonists (MRAs), or
  • sacubitril valsartan, with beta blockers, and, if tolerated, MRAs
  • For more information, see dapagliflozin under SGLT2 inhibitors (6.1.2 Antidiabetic drugs)

If symptoms persist despite first and second line treatments, consider:

• Cardiac resynchronisation therapy for patient with a wide QRS complex (pacing with or without a defibrillator)
• Digoxin (for worsening or severe heart failure due to left ventricular systolic dysfunction despite first and second-line treatments).