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                                                                 Updated 5/2/11

Heart Failure (HF) Treatment in the ELDERLY
                          Systolic (EF < 45%)

Step 1) Diuretics to control acute HF exacerbation
                                                 
Step 2) Add ACE-I when symptoms of HF stabilizing 1
                                                 
 
Step 3) Titrate ACE-I to optimal dose 2
Stop titration if: symptomatic with BP (< 90mm systolic) 3
                              &/or
         Cr
> 1.0 over baseline &/or K+ > 5.5
                                                    
Step 4) When ACE-I at optimal dose
            add: B-blocker (carvedilol or metoprolol) 4
                      Titrate to slowly:
Stop titration if: symptomatic w BP < 90mm systolic &/or HR < 50
                                                
 
Step 5) If HF persists:  Add Spironolactone 5
                                                
Step 6) If HF persists: Add Hydralazine & Isosorbide 6
                                                
 
Step 7) If HF persists: for men: Add Digoxin ≤ 0.125 mg/d 7

Guidelines for systolic HF:
1  Once HF stabilized always titrate to lowest dose diuretic (e.g. furosemide)
2  If side effects from ACE-I, use ACE-II (ARB) instead
   Optimal dose equivalent to enalapril 20-40mg/d or lisinopril 30-40mg/d
3  If symptomatic w BP < 90 systolic, choose to lower diuretic before
   ACE-I or B-blocker (if HF compensated)
4  Beta blocker: carvedilol: initial dose 3.125mg bid, titration
by
   3.125mg bid q 2-4 wks, max dose (25mg bid), metoprolol start 12.5mg bid
   titrate to 100mg bid by 12.5mg bid increments q 2 wks
5  In class IV; add spironolactone if preserved renal function and normal K+
6  Begin: Hydralazine start 10mg tid & titrate to max dose 100mg tid
   and ISDN start 10 tid & titrate to max dose 40mg tid (especially in Afr Am)
7  If HR > 90 despite B-blockers: add digoxin ≤ 0.125mg/d
   Keep level ≤ 0.8 ng/ml
   - avoid Ca+ channel blockers in all systolic CHF
   - consider cardiac resynchronized therapy (CRT) in systolic HF, with
     EF < 35%, sinus rhythm, with ventricular
dyssynchrony

 

HF Treatment in the Elderly
DIASTOLIC ("HFPEF") (EF > 45%)

Step 1) Diuretics to control acute HF exacerbation 1
                                              
Step 2) Once stable add: B-blocker 2
             
Titrate to max. dose slowly
            
 Stop titration if: symptomatic and BP < 90mm
           systolic 4  &/or HR < 50 BPM
                                     
Step 3) When B-blocker at max dose:
           Titrate ACE-I to optimal dose 3
           Stop titration if: symptomatic & BP (< 90mm systolic)4  
           &/or Cr
> 1.0 over baseline &/or K+ > 5.5
                                              
Step 4) If HF persists: Add Hydralazine & Isosorbide 5

For both diastolic and systolic HF:
Factors to address: anemia,
exercise, salt intake, HTN, humidity,
air conditioning,
air pollution, alcohol, avoid NSAIDS, evaluate
for IHD, thyroid dz.

Guidelines for diastolic CHF
1  Once HF stabilized always titrate to lowest dose diuretic (e.g. furosemide)
   (always use diuretics with caution in diastolic CKF)
2  Beta blocker: carvedilol: initial dose 3.125mg bid,
   titration
by 3.125mg bid q 2-4 wks, max dose (25mg bid)
   metoprolol (start) 12.5mg bid titrate to 100mg bid by 12.5mg bid increments
3  If side effects from ACE-I, use ACE-II (ARB) instead
   Optimal dose equivalent to enalapril 20-40mg/d or lisinopril 30-40mg/d
4  If symptomatic w BP < 90 systolic, choose to lower diuretic before
   ACE-I or B-blocker (if CHF compensated)
5  Begin: Hydralazine start 10mg tid & titrate to max dose 100mg tid and
   - avoid digoxin in diastolic HF

For more information see: Website: geriatrics.unmc.edu & visit GERI Pearls

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