Guidance aims to raise dosages in CHF to trial levels
New guidance for the treatment of patients with chronic
heart failure was published on 3 September during the European Society
of Cardiology meeting in Stockholm, Sweden. It is aimed at GPs and other
non-specialists and it is designed to encourage early use of angiotensin
converting enzyme inhibitors, b-blockers and spironolactone in patients
with CHF.
The authors, cardiologists from the United Kingdom,
Europe and the United States, call the guidance “practical recommendations”,
that will allow non-specialists to put the results of major clinical trials
and existing guidelines into practice. They say that surveys of both primary
care and hospital practice have shown that substantial proportions of
patients who should be treated with ACE inhibitors are not receiving them.
In addition, those receiving ACE inhibitors are often being treated at
doses lower than those used in clinical trials.
The new guidance sets out step-by-step clinical
recommendations for the use of ACE inhibitors, b-blockers and spironolactone.
These cover why treat, who to treat, when, in which setting, which agent
and dose, how to use, advice to patients and problem solving. Advice is
also given on the use of digoxin.
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Guidance for ACE inhibitors
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These should be used for most
patients.
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Drug
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Starting dose (mg)
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Target dose (mg)
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Captopril
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6.25 three times daily
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50–100 three times daily
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Enalapril
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2.5 twice daily
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10–20 twice daily
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Lisinopril
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2.5–5 once daily
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30–35 once daily
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Ramipril
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2.5 once daily
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5 twice or 10 once daily
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Trandolapril
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1 once daily
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4 once daily
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Start with a low dose. Double the dose at not less than two-weekly
intervals. Aim for target dose but remember that some ACE
inhibitor is better than none.
Advise patients of major adverse effects (eg, cough, hypotension).
Symptoms should improve within a few weeks to months.
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Guidance for b-blockers
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These should be used for patients
with mild to moderate CHF who are not asthmatic. Unstable
or severe CHF should be treated in hospital.
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Drug
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Starting dose (mg)
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Target dose (mg)
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Bisoprolol
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1.25 once daily
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10 once daily
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Carvedilol
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3.125 twice daily
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25–50 twice daily
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Metoprolol CR/XL
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12.5–25 once daily
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200 once daily
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Start with a low dose. Double the dose at not less than two-weekly
intervals. Aim for target dose but remember that some b-blocker
is better than none.
Advise patients not to stop
therapy without consultation. Symptoms should improve over
three to six months or longer.
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The main thrust of the guidance is that, unless contraindicated,
all patients with CHF should receive first an ACE inhibitor and then a
b-blocker (see Panels). Both drugs should be titrated up to achieve the
target doses used in the main clinical trials.
For patients with persistent or worsening symptoms,
spironolactone should be added at a starting dose of 25mg once daily or
on alternate days. This should be titrated up to a target dose of 25–50mg
once daily. Digoxin could have a role in patients with atrial fibrillation,
the authors say, and its use should not preclude subsequent introduction
of a b-blocker.
Professor Richard Hobbs, professor of primary care
and general practice, University of Birmingham, and one of the authors
of the guidance, says: “Many heart failure patients gain a new lease of
life once their heart failure is adequately controlled. It is unfortunate
that a majority of patients are either not offered or under-treated with
interventions which would improve both the length and the quality of their
lives. This new guidance is designed to answer common questions that non-specialist
health care professionals may have regarding heart failure treatment and
should, hopefully, encourage more doctors, especially those in primary
care, to adequately treat patients.”
The guidance was produced with the help of an unrestricted
educational grant from AstraZeneca (European Journal of Heart Failure
2001;3:495–502).
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