Heart Failure Medication Titration Plan

1 Heart F AILURE (HF) Medication OPTIMISATION - 08/2022DO NOT WRITE IN THIS BINDING MARGINPage 1 of 2 URN:Family name:Given name(s):Address:Date of birth: Sex: M F IHeart Failure (HF) MedicationOptimisation Plan State of Queensland (Queensland Health) 2022 Licensed under: : .. Dear ..Pl ea se op timise this patie nt s he art fai lure med ic ationsandcall the n umber below if there are an y sultsEF %:Date Wei ght (kg)eGFR mL/minK+ mmol /LBP mmHgHR bpmMonit oring recommendations(see overl eaffor guid ance) Checkbl ood pr essure(BP) inc lu dingposturaldrop andhe art rate (HR)eachvisit ACEI/ARB/ARNI/ MRA*: check serum potassiu m (K+), renal function 1-2 week/s after commenci ng or titrating(if K+ is high recheck in 48 hou rs). For MRAs check every 4 weeks for 12 weeks, at 6 months, then 6-monthly SGLT2i*: befo re commencing check volume status and for t ype 1 diabetics seek endocrin ologist approval Di uretic do se cha nge s beyond 3 days requi re medi cal review and checking of bl ood chemistry an d volumestatus Iron.

2 Order Hb*, CRP*, ferritin & transferrin saturation at first assessment and every 3-6 months if iron deficientThe 4 d rug classes that reduce Heart Failure mortality & morbidi tyCombination therapy is mor e effective than a sin gle medi ca tion at a hig herdose BUT avoi d simul taneous up Titration Class*Medic ation nameCurrentdo se/ frequen cyTargetdo se/frequencySchedule / InstructionsACEIARBARNImg mg Washout for 36 ho urs or more if switching from ACEI to ARNI or vice versa Increasedo seby:mg every week(s)Beta-bl ockerBisopr ol olCarvedi lol Metoprolol XLNebi vololmgmgIncrease do se by: mg every week(s)MRAEple ren oneSpironolactonemgmgIncrease d oseon ce stable on other Heart fai lure medic ations. SGLT2iDapag liflozi nEmpagli flozinmgN/AA transient fal l in eGFR (up t o 30%) is common an d not usuall y clini ca ll y sign if if perio perative or that provide symptom relief DiureticFurosemi de Bumetani dePatient ha s a diu retic acti on pl anAdju st diuretic do se acc ording to clinical assessment ( , increase dose 50 100% if fl ui d overl oaded)Iron in fusionDate of infusion (if given): (oral iron is ineffective with Heart fai lure)Pleas e check iron studies (see monitoring above).

3 Give an iron i nfusion if ferritin is less than100 g/L or100-299 g/L with a tran sferrin saturati on be low 20%. Contact ho spital if unable t o provid e i :Cons ul tant s name: .. Authoris ed by(Dr/NP): ..Authoris er signature: ..Date: .. Heart Failure Service : .. *ACEI: angiotensin-converting-enzyme inhibi tor; ARB: angiotensin II receptor bloc kers; ARNI: angiotensin receptor neprilysin inh ibi tor; MRA: mineralocorticoi d receptor antagoni st; SGLT2i: sodium-gluc os e cotransporter-2 inhibitor; Hb: haemogl obin; CRP:C-reacti ve protein; Esti mated Glomerular Filtration Rate (eGFR)Name / Designati on(Affix identification label here)SW1163 Page 2 of 2(Affix identification label here)URN:Family name:Given name(s):Address:Date of birth: Sex: M F IHeart Failure (HF) MedicationOptimisation PlanFacility.

4 Medications that may cause or worsen HFNon-steroi dal a nti-infl ammatorie s, cyclooxygenase-2in hibitors; centr al ly acting calcium channel bl ockers(verapamil, dilti azem), corticosteroid s, tricyclican tid ep ressan ts, saxagl iptin, moxonid ine ,thiazo li din edione s (glitazones )HypotensionAsymptomatic hypotension usua ll y req uire s no change i ntherapy (unless systol ic BP is consistently less tha n90 mmHg).Symptomatic hypotension1. Stop or reduc e calcium-channel bl ockers and/or 1. other vaso di lat ors unless essen tia l , f or an gin Consider redu cin g diu retic dos e if the re are noii. signs or symptoms of conge st io Temporarily redu ce ACEI, ARB, ARNI or beta-blocker dose if ab ov e meas ures do not work.

5 Avoid abru pt cessatio n of be ta blockers unless pati en t is in shock*.IV. Review pati en t within a w ee k an d seek spec ial ist advice if the above measures do not work.* For severe hypo tension or shock, refer t o hospita lemerg en cy depa rtment (ED).Worsening renal functionCautions for renal function Cauti on with ARNI if eGFR is le ss tha n 30mL/min. eGFR does not accurately reflect renal f un cti on wher e body weight is very low (t en ding to overestimate) or when volume change is rapi d. Where t he re is severe deh ydration, sepsis, or medic ation i nduced nephroto xicity refer t o ED. Consider withholding MRA firs t, t he n SGLT2i, followed by ACEI, ARB or ARNI un til pati en t is commencin g or t itrating thera py: Expect a rise i n creatinine, urea , an d po tassium (K+) for ACEI, ARB, ARNI, or MRA.

6 A decli ne in eGFR up t o 30% is accepta ble if it stabil ises wi thin 2 weeks (or 4 to 12 weeks for SGLT2i). If eGFR decli nes by more than 30%, review fluid status and nephrotoxic medi cations and seek speci al ist advic e about safety of continuing tion or peripher al oedema Increase t he diuretic dose, the n gradual ly redu ce beta-blo cker dose (avoiding a brupt cessati on). Liai se with the he art fai lure service and review the patie nt daily or weekly (as appropria te). Seek spec ia list advice if symptoms do not im prove. If deterioration is severe, refer patient to ED. Br adyca rdia Where HR is less tha n 50 beats per minute, an d the patie nt is on a be ta-blo cker, review t he need for other dru gs that slow Heart rate ( , digoxin, amioda ro ne ) in consultation w ith specialist; a nd arrange ECG to exclude h ea rt bl ock.

7 Consider redu cin g bet a-blocker (avoid ing a br up t cessatio n) if bradycardi a is symptomatic. If pacemaker is present, seek speci al ist la emiaMonitor K+ for ACEI, ARB, ARNI an d MRA. Urgently check K+, creatinine and urea for dehydration or serum K+ is: mmol/L redu ce or withh old K+ supple ments and check die t mmol/L perform ECG and with hold K+ supple ments and reduce K+ retaining ag ents espec ia lly MRAs (less so f or ARNI, ACEI & ARB) 6 mmol/L or more, urgently seek spec ia list advice Recurrently high, seek speci alist ad viceVolume depletionSGLT2i, MRA and ARNI have a mild di uretic volu me st atus before commencing o r adju sti ngdo ses and reduce t he d ose o f loop diuretic ineu vo la emic patie nts if Exclude pul mona ry oede ma or reflux as a cause if cough is new or worsening.

8 Only stop implicated dru gs if cough is not tol erable and consider sub stituting ACEI wi th ARB or (rare) Stop ACEI, ARB, or ARNI immediately, and consi de r referral t o an immunol ogi st. If t he re is a history of ACEI related angioedema, seek specia list advice before trialling ARB due to possibl e cross-sensitivity. Avoid ARNI if an gioedema is due t o ACEI or ketoacid osis (rare)SGLT2i increase the risk of ketoacidosis in diabeticpa tie nts. Endocrinologist review is advised be forecommencing in patients with t yp e 1 diabetes. The riskin creases when the pati en t has missed or r ed uc edin sulin doses, is fasting, perio perative, on a ketogeni cdiet, dehy drate d, or has vomiting or guide is not intended t o replace clinical judgment