![]() ‘You can call the cardiologist if a patient is deteriorating and ask them to see the patient. Once the relationship with a cardiologist is established, GPs gain access to the cardiologist’s guidance and management when urgently needed, says Professor Audehm. 7 The all-cause readmission rate is 20% and all-cause mortality is 8% 30 days after hospitalisation with heart failure. Indeed, only 50% of people with heart failure are alive 5 years after diagnosis. Heart failure has dreadful mortality and morbidity that we can approach with the same intent,' he says. 'We wouldn't think twice about an annual review for a patient with, for example, kidney disease. 'A shared care approach, where a cardiologist who specialises in heart failure reviews your patient once a year, is a good thing,' says Professor Audehm. At the same time patients can benefit from a referral to a cardiologist specialising in heart failure. GPs can play a vital role with initiating and implementing up-titration of heart failure medicines. Or if their heart rate is a little bit too low and they’re symptomatic, I would leave the beta blocker and up-titrate the ACE inhibitor.’ 'For example, if the patient is feeling a little bit more dizzy than normal, I would leave the ACE inhibitor and up-titrate the beta blocker first. 'Variations to the above may be required to address adverse effects, particularly when they are symptomatic, in response to their medications. Then we’d up-titrate all three medications in turn until we reach target doses for each one. At some point before reaching their target doses, we’d start an MRA. 'Most of our patients start with an ACE inhibitor, then start the heart failure beta blocker, then increase the ACE inhibitor, then increase the beta blocker. Now it’s realised the combined effect of more than one medication already started at low doses and then up-titrating all of them in turn is more beneficial and this has become the standard approach. 'Years ago the guidance was quite fixed about up-titrating one medication to maximum dose, then up-titrate the second one and so forth. Professor Driscoll is a Heart Failure Nurse Practitioner at Austin Health, Melbourne and co-author of the National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand Heart Failure Guidelines 2018. ![]() 1ĪCE inhibitors, ARBs and ARNIs may be regarded as a single group of medicines for the purposes of up-titration and adverse effects. ![]() volume status Table 5, and miscellaneous Table 6.įurther down the pathways, for people with persistent HFrEF with left ventricular ejection fraction (LVEF) ≤ 40%, it’s recommended to change the ACE inhibitor (or ARB) to an angiotensin receptor-neprilysin inhibitor (ARNI). See guidance on blood pressure Table 2, heart rate Table 3, renal function Table 4. If adverse effects don’t improve sufficiently, the patient may be considered to have reached maximum tolerated dose. These variations include reducing dosage and pausing up-titration of a medicine with the aim of reducing or stopping the adverse effects to enable up-titration to target dose to be restarted. In addition, variations during up-titration may be necessary for patients who experience certain adverse effects, particularly those that are symptomatic. review every 1–2 weeks after each medicine initiation and dose increase, including a clinical review and checking blood pressure, heart rate, renal function.add the next medicine before reaching target or maximum tolerated dose, eg, if the patient is euvolaemic, a heart failure beta blocker may be started before achieving target or maximum tolerated dose of an ACE inhibitor.double the dose of heart failure medicines, one at a time, every 2–4 weeks (except MRAs up-titrated in 4–8 weeks), or as tolerated.However rather than a single up-titration pathway to reach this goal, there are two pathways that are differentiated by the patient’s volume status when starting pharmacological management euvolaemic or congested. Copyright 2019 by National Heart Foundation of Australia. Clinical factsheet: pharmacological management of chronic heart failure with reduced left ventricular ejection fraction (HFrEF). * From the National Heart Foundation of Australia 2018. HFrEF = Heart failure with reduced ejection fraction ACEI = angiotensin-converting enzyme inhibitor ARB = angiotensin receptor blocker ARNI = angiotensin receptor neprilysin inhibitor MRA = mineralocorticoid receptor antagonist D: daily BD: twice daily TDS: three times a day MR: modified release Table 1: Start and target doses for heart failure medicines for people with HFrEF 7 gradually up-titrate them to target or maximum tolerated doses.The process of up-titration recommended by Australian guidelines to reach the goal of a combination of heart failure medicines is to: 1,4
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