Many heart medications will remain important in managing the patient’s symptoms even in the advanced stages of heart failure, e.g. furosemide for breathlessness secondary to fluid overload and their management is often done in discussion with the heart failure team. In all case consider treating any triggers and comorbidities.
Seek advice from cardiology teams
Heart failure with reduced ejection fraction (HFref)
- Sacubitril/Valsartan
- MRA
- SGLT2i (Dapagliflozin)
- Betablockers, possibly also ivabradine if patient in sinus rhythm and hypotension a concern
- Consider restoring to sinus rhythm if new onset of AF
Heart failure with preserved ejection fraction
Only evidence base is for;
- Diuretic therapy
- SGLT2i
- Treat triggers and comorbidities
- Consider restoring SR if new onset of AF
For the management of peripheral and pulmonary oedema.
Loop diuretics: furosemide and bumetanide.
Equivalent doses of loop diuretics:
- 40mg Furosemide is equivalent to 1mg Bumetanide
- When converting from oral to SC or IV route, consider improved bioavailability therefore 3mg Bumetanide would be converted to between 80-120mg SC/IV furosemide
Thiazide diuretics: Metolazone 2.5-5mgs (unlicensed, but used and cost effective, good bioavailabiity orally)
Chlortalidone.
Potassium-sparing diuretics and mineralocorticoid receptor antagonists: spironolactone and eplerenone, very effective in combination with above particularly in presence of congestive or right sided heart failure and to assist with prevention of hypokalaemia.
Rate control
Betablockers eg bisoprolol, metropolol, carvedilol.
Digoxin particularly if hypotensive.
Seek advice from cardiology team regarding specialist heart medications
Heart failure with reduced ejection fraction (HFref)
- Sacubitril/Valsartan
- MRA
- SGLT2i (Dapagliflozin)
- Betablockers, possibly also ivabradine if patient in sinus rhythm and hypotension a concern
- Consider restoring to sinus rhythm if new onset of AF
Heart failure with preserved ejection fraction
Only evidence base is for;
- Diuretic therapy
- SGLT2i
- Treat triggers and comorbidities
- Consider restoring SR if new onset of AF
In end-stage heart failure, furosemide via subcutaneous infusion may be an appropriate option to attempt control of symptoms related to fluid overload.
Commencement and management of furosemide via CSCI requires a multi-disciplinary approach. Specialist advice from palliative care and heart failure teams can support decision-making.
See our specialist guidelines here:
www.westmidspallcare.co.uk/spagg/
Disclaimer
This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.