National Medicines

Information Centre

VOLUME 18
NUMBER 3
2012

ST. JAMESS HOSPITAL DUBLIN 8

TEL 01-4730589 or 1850-727-727 FAX 01-4730596 www.nmic.ie

CHRONIC HEART FAILURE

Heart failure presents as a complex clinical syndrome, making diagnosis difficult in the early stages;
confirmatory diagnostic tests are required
Normal levels of natriuretic peptides make the diagnosis of heart failure unlikely, in the absence of
cardiovascular disease
Patients with heart failure should be managed initially with an ACE inhibitor, -blocker and diuretic
Aldosterone antagonists may improve survival and reduce hospitalisations in heart failure patients
who are still symptomatic despite optimal first-line therapy

INTRODUCTION

It is estimated that up to 2% of the adult population in developed countries has heart failure, with the prevalence rising to >10%
among those aged > 70 years.1 Because it is primarily a condition of the elderly, mortality and morbidity remain high with
heart failure, despite advances in diagnosis and therapy.2,3 Heart failure is reported to account for 5% of all emergency medical
admissions, of which 80% are patients > 65 years of age.2,4
Current data suggest a 2% prevalence of symptomatic heart failure in the Irish population (rising to 10% in those > 75 years), with
a further 2% having asymptomatic left ventricular systolic dysfunction at risk of progressing to symptomatic failure; over 10,000
new cases are diagnosed annually.5 Therefore heart failure is more common than most cancers and represents a major public
health burden.5 This bulletin will outline current guidance on the diagnosis and management of chronic heart failure.

DEVELOPMENT OF HEART FAILURE

Heart failure can arise as a result of many diverse forms of cardiovascular disease (CVD) including coronary artery disease,
hypertension, valvular disease, congenital disease and viral heart disease.3 Figure 1 outlines the stages in the development and
progression of heart failure.
Figure 1: Stages in the development and progression of heart failure4,6
Stage A
Stage B
Stage C
Stage D
At high risk of HF,
but without HF symptoms or
structural heart disease

Structural heart disease present

but no signs / symptoms of HF

Structural heart disease present

with prior / current HF symptoms

Refractory HF requiring
specialised interventions

e.g. patients with: HT,

e.g. patients with: previous MI,
e.g. patients with: known
e.g. patients with marked
atherosclerotic disease, DM,
LVH, low ejection fraction,
structural heart disease +
symptoms of HF at rest despite
obesity, metabolic syndrome,
valvular disease
shortness of breath, fatigue,
maximum medical therapy
cardiac toxins*, positive FHx of
exercise tolerance
cardiomyopathy
*include drugs such as cytotoxic agents, drugs of abuse, alcohol; HF = heart failure; HT = hypertension; DM = diabetes mellitus; MI = myocardial infarct;
LVH = left ventricular hypertrophy; FHx = family history

The role of risk factors e.g. existing CVD in the development of clinical heart failure is well recognised. In addition, a recent report
from the Framingham Heart Study suggested that dysfunction in non-cardiac organ systems (such as anaemia, renal dysfunction,
or lung disease) can interact with a structurally or functionally abnormal myocardium to hasten the progression to overt heart
failure.7,8 Since early intervention may reduce the development and progression of structural heart disease (and improve morbidity
and mortality) in those patients judged to be at stage A or B (Figure 1), treatment strategies should include management of both
existing cardiac and non-cardiac organ disease.4

DIAGNOSIS AND CLASSIFICATION

Heart failure presents as a complex clinical syndrome that suggests the efficiency of the heart as a pump is impaired.2 Diagnosis
may be difficult, especially in the early stages.1 Table 1 outlines symptoms and signs of heart failure.
Table 1: Symptoms and signs of heart failure1
Symptoms
Signs
Typical
More specific
Breathlessness, orthopnoea, paroxysmal nocturnal dyspnoea, ankle
swelling, fatigue, tiredness, exercise tolerance or time to recover
after exercise

Less typical

Elevated jugular venous pressure, hepatojugular reflux, gallop rhythm,

laterally displaced apical impulse, cardiac murmur

Less specific

Weight gain (>2kg/week), bloated feeling, loss of appetite, confusion Peripheral oedema (ankle, sacral, scrotal) pulmonary crepitations,
(especially in the elderly), depression, palpitations, syncope
air entry and dullness to percussion at lung bases (pleural effusion),
tachycardia, irregular pulse, tachypnoea (>16 breaths/min), ascites,
hepatomegaly, tissue wasting

Diagnosis of heart failure involves a careful history and clinical examination, to identify signs and symptoms suggestive of
cardiac dysfunction (see Table 1) which should be confirmed by diagnostic tests.3,9 A 12-lead ECG provides information on
ischaemic changes, prior MI, rhythm and left ventricular hypertrophy. Echocardiography (ECHO) is normally the preferred
investigation of cardiac function.3 Measurement of serum natriuretic peptides (BNP or NTproBNP) is helpful in patients with no
prior CVD, or when ECHO is non-specific or not readily available. Normal levels of natriuretic peptides make the diagnosis of
heart failure unlikely, in the absence of CVD.2,3 However, the exclusion threshold differs depending on whether there is an acute

onset / worsening of symptoms or whether there is a more gradual onset of symptoms.1 In addition, natriuretic peptide levels increase
with age but may be reduced in obese people. Therefore evaluation of the results should take into account the individual patient.
Chest x-ray may provide information on pulmonary congestion or identify an alternative cause for the symptoms; but significant left
ventricular dysfunction may be present in the absence of chest x-ray signs.1
Classification: Once a diagnosis is made, the symptomatic severity of heart failure is classified according to the New York Heart
Association (NYHA) functional classification (Table 2). However, symptom severity correlates poorly with ventricular function
and although there is a clear relationship between severity of symptoms and survival, patients with mild symptoms may still have a
relatively high absolute risk of hospitalisation and death.1,10 A study, undertaken in new referrals to a heart failure clinic, showed that
patients categorised as NYHA 1 heart failure (n=439) had significantly reduced peak exercise capacity, renal impairment, cardiac
conduction tissue disease and elevated mortality risk compared with matched controls.11
Table 2: New York Heart Association (NYHA) classification of heart failure10
Class I
Class II
Class III
Class IV
No limitation of physical activity:
no symptoms*

Slight limitation of physical

activity: comfortable at rest but
ordinary physical activity causes
symptoms*
* symptoms = undue breathlessness, palpitations or fatigue

Marked limitation of physical

activity: comfortable at rest but
less than ordinary activity causes
symptoms*

Breathless at rest: unable to carry

out any physical activity without
discomfort

Heart failure may also be classified on the basis of ejection fraction. At least 50% of heart failure patients present with left
ventricular systolic dysfunction, which is associated with a reduced ejection fraction (HF-REF).2 The remainder are found to have
either normal or no significant reduction in left ventricular ejection fraction so-called preserved ejection fraction (HF-PEF). It is
thought that most HF-PEF patients have left ventricular diastolic dysfunction, although this may not account for all their symptoms.
Patients with HF-PEF tend to be older, more often female and obese, less likely to have coronary artery disease but more likely to
have hypertension and atrial fibrillation.9 This classification is important because management of these underlying conditions in
addition to symptomatic management of heart failure is an important aspect of overall care.3,9

MANAGEMENT OF HEART FAILURE

The goals of treatment are (1) to improve symptoms (2) reduce hospitalisations and (3) reduce mortality.

LIFESTYLE MANAGEMENT

Because heart failure requires life-long care, management should involve a multidisciplinary approach, with families as well as
patients being encouraged to become involved. Advice and education on lifestyle changes should be given including: smoking
cessation, diet and nutrition (including restriction of salt intake to 2-3g/day and weight reduction if overweight) and advice on alcohol
reduction / cessation, depending on the nature of their condition.10 Exercise training also plays an important role in heart failure
management. A recent review involving >3,600 patients with mild to moderate heart failure, showed a reduction in hospitalisations
and a significant improvement in health-related quality of life with exercise training programmes, compared with usual care.12 The
benefits of exercise are thought to be in addition to those achieved with pharmacotherapy.4 Exercise training for heart failure
should only be undertaken in patients with stable disease and in conjunction with pharmacological management. It should
follow a formal protocol (e.g. 30 minutes of moderate activity, 5 days per week, with warm up and cool down exercises) and
ideally be part of cardiac rehabilitation programmes for other types of CVD.4 The Irish Heart Foundation has produced a helpful
patient booklet entitled living well with heart failure, which is available to download at: http://www.irishheart.ie/media/pub/
patient_booklets/living_with_heart_failure.pdf.

PHARMACOTHERAPY: INITIAL TREATMENT

The goals of pharmacotherapy are to (1) improve the patients symptoms and (2) prevent or delay structural heart disease.
Most clinical trials have been undertaken in patients with HF-REF therefore current guidance relates primarily to this group of
patients. Most patients with heart failure should be routinely managed with a combination of 3 types of drugs: an angiotensin
converting enzyme inhibitor, ACEI (or angiotensin receptor blocker (ARB) if intolerant of ACEIs), a -blocker and a diuretic to
relieve the signs and symptoms of congestion.1,2,4 Table 3 outlines the most frequently prescribed medicines in these classes in Ireland.
Table 3: Medicines used in the first line management of heart failure2,13-23
Drug Class
Recommended Dosage Regimen
Class Side Effects
Cost*

ACEIs**
Postural hypotension; dry cough; plasma K+;

Ramipril
1.25 10mg daily (2 divided doses)
caution with renal dysfunction. Rarely angio-oedema.
4.90
Perindopril
2.5 5mg daily
Not to be used during pregnancy
11.30
Lisinopril
2.5 35mg daily
4.70
Enalapril
2.5mg daily 10-20mg twice daily
6.30
Captopril
6.25 50mg three times daily
6.90
-blockers***
Bradycardia; worsening of heart failure; hypotension;

Bisoprolol
1.25 10mg daily
fatigue; GI disturbances; cold extremities
2.98
Nebivolol
1.25 10mg daily
6.16
Carvedilol
3.125 25mg twice daily
11.15
Diuretics:
Loop diuretics: K+ and Na+ ; hypovolaemia;

20 40mg once or twice daily

Furosemide
0.83
hypotension; creatinine; risk of gout
0.5 - 2mg daily (may give as 2 doses)
Bumetanide
Thiazides: K+ ; risk of gout; risk
3.07
2.5mg daily 10mg daily
Bendrofluof diabetes mellitus. Rarely Na+
3.20
methiazide
NOTE: Each medicine should be initiated at a low dose and titrated upwards (usually at 2 weekly intervals) according to individual response, plasma
potassium and renal function to achieve optimum dose. Check Summary of Product Characteristics (SmPC) for specific product information [see also
Figure 2 for advice on initiation of medicines]
* average monthly cost per item, derived from national data in the HSE-Primary Care Reimbursement Scheme (PCRS) Dec. 2011
**5 most frequently prescribed ACEIs (as single agents, based on national data from the HSE-PCRS Dec. 2011) are listed. Other agents in this class are
also authorised for use in heart failure - check the individual SmPC.
***-blockers licensed for use in heart failure; cardioselective -blockers; also inhibits alpha adrenergic receptors
ACEI = angiotensin converting enzyme inhibitor; K+ =potassium; Na+ =sodium

Angiotensin converting enzyme inhibitors (ACEIs) inhibit the renin-angiotensin-aldosterone system (RAAS), by blocking the
conversion of angiotensin I to angiotensin II. They have been shown to reduce death, hospitalisation or myocardial infarction,
compared with placebo, in several randomised controlled trials (RCTs) undertaken in patients with clinical heart failure or significant
left ventricular dysfunction.1,24 Beneficial effects on mortality are observed rapidly within a few weeks of starting treatment,

increase with duration of treatment and are independent of age, sex and baseline use of diuretics, aspirin and -blockers.24
They are reported to have a modest effect on LV remodelling. Therapy should be initiated at a low dose and slowly titrated upwards
to optimal response. Anticipated side effects include symptomatic hypotension, hyperkalaemia, cough and renal dysfunction but in
general these are not life-threatening and are usually reversible upon stopping the drug or reducing the dose (Table 3).
-blockers act as competitive antagonists at -adrenergic receptors. Most of the clinical data on the benefits of -blockers in heart failure
have come from trials where patients were already receiving an ACEI +/- a diuretic.4 The collective experience (> 20,000 heart failure
patients) indicates that long-term -blocker treatment can improve the patients clinical status and can reduce the combined
risk of death or hospitalisation. The results also suggest a complementary mode of action for ACEIs and -blockers resulting in
additive beneficial effects in terms of disease-modifying activity.1,4 Anticipated side effects include bradycardia, bronchospasm,
fatigue, masking of hypoglycaemia in diabetic patients, worsening of peripheral vascular disease and cardiac decompensation (Table
3). However, current guidelines suggest that -blockers may be used safely and effectively in patients with stabilised heart failure
and left ventricular systolic dysfunction, with concomitant diabetes mellitus, peripheral vascular disease and mild-moderate chronic
obstructive pulmonary disease (must be without reversible airways obstruction) using a start low, go slow dosage administration,
with assessment of clinical status after each upward titration.2,10 Cardioselective agents are available; specialist supervision may be
required on an individual basis.18,19
Diuretics are the most commonly prescribed class of drugs in chronic heart failure patients. They produce diuresis by interfering with
the reabsorption of sodium at different sites in the kidney tubule.9,25 In short-term studies diuretic therapy resulted in reduction of
pulmonary congestion, peripheral oedema and body weight within days of initiation of therapy.25 In intermediate-term studies,
diuretics have been shown to improve cardiac function, symptoms and exercise tolerance in heart failure patients.25 There have been
no long-term studies with loop or thiazide diuretic monotherapy, therefore their effects on mortality are not known.4,25 Optimal use
involves initiation with a low dose of diuretic which is titrated until urine output increases and weight decreases (0.5 1.0kg daily).4
Once the fluid retention has been resolved, maintenance diuretic treatment, with regular electrolyte monitoring, is recommended. Dosage
should be reviewed regularly as it may need frequent adjustment; patients may be educated to record their weight daily and adjust
their diuretic dosage according to pre-specified range.4 Patients may also need to be supported to ensure adherence to diuretic therapy.

SECOND LINE TREATMENTS

Angiotensin Receptor Blockers (ARBs) also block the RAAS; they inhibit the binding of angiotensin II to the angiotensin
II type 1 (ATI) receptor (Table 4).26 They are recommended for use in heart failure patients as an alternative to ACEIs (in the presence
of ACEI intolerance such as cough, angioedema).1,2,4
Table 4: Medicines used in the second-line management of heart failure1,26-31
Drug Class
Dosage Regimen
Class Side Effects
Cost*
ARBs**
Valsartan
Losartan
Candesartan
Aldosterone
(mineralocorticoid
receptor) Antagonists***
Spironolactone
Eplerenone

40-160mg twice daily

12.5 150mg daily
4 32mg daily

12.5 50mg+ daily

25 50mg daily

Postural hypotension; plasma K+; caution with renal dysfunction.

Not to be used during pregnancy
plasma K+ - discontinue if K+ levels > 5mmol/L; caution with
renal function.
Gynaecomastia (with spironolactone).
Do not use eplerenone with strong inhibitors of CYP 3A4****

13.63
15.49
21.72

6.02
59.03

NOTE: each medicine should be initiated at a low dose and titrated upwards (usually at 2 weekly intervals) according to individual response, plasma K+ and
renal function to achieve optimum dose. Check SmPC for specific product information
*based on national data from the HSE-PCRS, December 2011
**ARBs licensed for use in heart failure; ***under specialist supervision, dosage must take into account concomitant therapies which K+
****includes clarithromycin, telithromycin, nefazodone, ketoconazole, itraconazole
ARB=angiotensin receptor blocker; K+ =potassium; CYP = cytochrome P450 enzyme system

There are conflicting results on the beneficial effects of ARBs in terms of morbidity and mortality in heart failure and therefore they
are not recommended as first-line agents.2,26 Similarly the addition of an ARB to an ACEI plus a -blocker is not recommended
as first choice in second-line therapy because of the availability of more effective alternative agents and the risks of hypotension,
hyperkalaemia and renal dysfunction with this combination.1,2,26
Aldosterone Antagonists/ Mineralocorticoid Receptor Antagonists (MRAs): Studies have shown that aldosterone levels are
elevated in heart failure patients, despite maximal RAAS system blockade.4 Persistently elevated aldosterone levels are thought to
play an important role in the structural development of heart failure (Figure 1), to correlate with disease severity and may also predict
mortality.10,32 RCTs have shown that, compared to placebo, MRA therapy can improve survival and reduce hospitalisations in
patients with both severe heart failure and also in symptomatic patients with milder heart failure, when added to standard
first-line therapies.33,34.35 Based on these findings, MRAs are now recommended as first-line add-on therapy for eligible heart failure
patients (i.e. based on renal function and plasma potassium level), who are still symptomatic despite optimal triple therapy. Although
MRAs are weak diuretics, there have been reports of potentiation of the diuretic effects of concomitantly administered loop or
thiazide diuretics, resulting in hypovolaemia and the risk of renal damage.4 Therefore, patients receiving this combination therapy
should be under specialist review and be subject to regular safety monitoring (see Table 4). The concomitant use of an ACEI, MRA
and ARB is not recommended because of the risk of severe hyperkalaemia.4

OTHER TREATMENTS USED IN HEART FAILURE

Digoxin has been used for many years in the management of heart failure, however the proven efficacy of ACEIs and -blockers
has caused a re-evaluation of its role in heart failure patients in sinus rhythm, especially in view of its narrow therapeutic index.36 A
recent review of clinical trial data suggests that digoxin may improve clinical status and reduce hospitalisations in patients with
heart failure who remain symptomatic, despite therapy with ACEIs, diuretics and possibly also -blockers.36 It should be used
with caution in patients at risk for arrhythmias as one large study suggested an increased risk of fatal arrhythmias.36
Ivabradine acts directly on the sinus node to slow the heart rate in the presence of sinus rhythm.37 It is not recommended in patients
with atrial fibrillation or other cardiac arrhythmias that interfere with sinus node function. It has shown benefit in terms of reduced
symptoms and hospitalisation in heart failure patients already on first-line therapy whose resting heart rate is 70bpm.1,38 Current
guidance suggests it may have a role in heart failure patients whose resting heart rate is 75 bpm despite optimal -blockade,
or when they cannot take -blockers.3,4 It should not be used with medicines which cause QT interval prolongation.37 It is
metabolised by cytochrome P450 (CYP) isoenzyme 3A4 therefore this must be taken into account before co-prescribing inhibitors

of CYP 3A4 (see SmPC for full details).37

Studies have shown that the combination of hydralazine + isosorbide dinitrate (which produces both venous and arterial
vasodilation) reduced cardiac mortality and morbidity (with better quality of life) in black populations of African and Caribbean
descent.2,10 It may also be considered in non-black populations who remain symptomatic despite, or cannot tolerate, optimal standard
therapy; there are insufficient data on its effect on cardiac mortality for this target patient group (11).1,10 This combination should
only be used under specialist supervision. [NOTE: neither medicine is currently licensed (as an oral preparation) in Ireland]
Anticoagulants: Heart failure has been recognised to predispose individuals to stroke and thromboembolism; this has been
estimated as an annual stroke risk of approximately 1.5% in mild-moderate heart failure versus an annual risk of 0.5% in
the general population without heart failure.39 A recent review concluded that there is no convincing evidence that oral
anticoagulant therapy modifies mortality or vascular events in patients with heart failure and sinus rhythm. Therefore its
use is recommended only for certain groups of patients with heart failure (e.g. patients with atrial fibrillation).39
Anti-arrhythmic agents: Ventricular arrhythmias are common in heart failure, especially severe heart failure, and sudden cardiac
death continues to account for a significant proportion of disease-related mortality.10 However anti-arrhythmic agents currently
are not recommended for routine prevention of ventricular arrhythmias because they may have negative inotropic and/
or pro-arrhythmic effects in heart failure patients.4,10 Amiodarone, which has a sympatholytic effect on the heart in addition
to its anti-arrhythmic effects may be considered for use, under specialist supervision in high-risk patients.10,40 It is also used in
conjunction with implantable devices (see below). Amiodarone is an inhibitor of CYP 2C9 and CYP 3A4, therefore the potential
for drug-drug interactions with co-prescribed drugs must be carefully monitored.2,40
Non-surgical interventional therapies: Studies have shown that implantable cardioverter-defibrillators (ICDs) improve
survival compared with placebo or amiodarone in patients with ischaemic or dilated cardiomyopathy-related heart failure.1 They
should only be considered for patients, expected to survive for at least one year, after a sufficient period of optimised medical
therapy (3 months) and only if the ejection fraction remains persistently low.1 Amiodarone may be useful to treat recurrent
discharges with ICDs, which can lead to a reduced quality of life for the patient.4 Cardiac Resynchronised Therapy (CRT)
aims to reduce dyssynchronous ventricular contraction (recognised as abnormal cardiac conduction on an ECG), using a specific
pacemaker device. There is evidence that it can improve symptoms, quality of life and survival.4

MANAGEMENT OF CONCOMITANT CONDITIONS

Patients with heart failure frequently have risk factors for / evidence of other CVD including hypertension, atherosclerotic
disease, diabetes mellitus, metabolic syndrome (Figure 1). In addition to managing the symptoms of heart failure, all CV comorbidities must be actively treated to minimise further structural damage to the heart.1 Heart failure patients should also
be actively monitored for non-cardiac morbidities (e.g. lung or kidney disease) which may result from heart failure but which
may precipitate cardiac decompensation if not actively managed.1 Heart failure patients should receive pneumococcal vaccine
and annual influenza vaccination.10 It is also recommended to avoid medicines such as NSAIDs and glitazones, which may
worsen heart failure.1

MANAGEMENT OF HEART FAILURE PATIENTS WITH PRESERVED EJECTION FRACTION

There is much less evidenced-based guidance available for this patient group.2,3 As mentioned previously, these patients frequently
have various co-morbidities such as diabetes mellitus, hypertension, atrial fibrillation.3 The main treatment strategy for this
group is to 1) use diuretics to control oedema 2) manage hypertension and myocardial ischaemia if present 3) control
atrial fibrillation and 4) actively manage other co-morbidities such as diabetes mellitus. The decision to use the other
therapies recommended for HF-REF should be taken at individual patient level, based on overall status.10Although calcium
channel blockers (with the exception of amlodipine, felodipine or lercanidipine) are not routinely recommended in patients with
HF-REF, because of their negative inotropic effects, they may be used in this patient group.1,4

SUMMARY

The management pathway of patients with heart failure in clinical practice is summarised in Figure 2.
Figure 2: Management Pathway for Heart Failure1,2,4
Diagnosis

Take detailed history and perform clinical examination; confirm heart failure by
ECHO and/or serum natriuretic peptide levels. Assess the severity of symptoms

Treatment

In addition to education on lifestyle management and exercise training:

Step 1:*

ACE inhibitor (or ARB if ACEI not tolerated) +/- -blocker**

Concomitant therapy with -blocker + ACEI (or ARB if ACEI not tolerated)
If still symptomatic with optimised triple therapy (ACEI, -blocker, diuretic)

Step 2:*

ADD mineralocorticoid receptor antagonist (MRA) (ARB may be considered if

MRA not suitable)
[hydralazine + isosorbide may be useful in black populations / patients not
responding or intolerant of step 2 combinations]

PLUS
Diuretic therapy to relieve clinical congestion.
Regular review of symptoms and dosage
adjustments as required. Regular monitoring
of plasma K+ and kidney function. Active
management of co-morbidities.***
Advice on medication adherence
Under specialist supervision. Regular
review of symptoms and dosage
adjustments as required. Regular monitoring
of plasma K+ and kidney function. Active
management of co-morbidities.*** Advice
on medication adherence.

Under specialist supervision. Regular review

Consider adding in digoxin / ivabradine / use of non-surgical interventional
and monitoring as above.
therapies (ICD, CRT)
* guidance based on randomised controlled trials undertaken in heart failure patients with reduced ejection fraction
** the decision to start with monotherapy or dual therapy in step 1 depends on the patients status and suitability for each medicine
*** includes anaemia, renal and pulmonary dysfunction, diabetes mellitus, other CVD such as hypertension, coronary artery disease
the combination of ACEI plus ARB plus MRA should NOT be used because of the risk of severe hyperkalaemia
ECHO = echocardiography; ACEI = angiotensin converting enzyme inhibitor; ARB = angiotensin receptor blocker; K+ = potassium; ICD = implantable
cardioverter defibrillator; CRT = cardiac resynchronised therapy
Step 3:*

FOR PERSONAL USE ONLY. NOT TO BE REPRODUCED WITHOUT PERMISSION OF THE EDITOR

List of references available on request. Date of preparation: August 2012

Every effort has been made to ensure that this information is correct and is prepared from the best available resources at our disposal at the time of issue.
Prescribers are recommended to refer to the individual Summary of Product Characteristics (SmPC) for specific information on a drug.

References for Heart Failure: NMIC 2012; 18: 3

1. McMurray JJV et al, ESC guidelines for the diagnosis and treatment of acute
and chronic heart failure 2012. European Heart Journal
doi:10.1093/eurheartj/ehs104
2. Chronic heart failure: National clinical guideline for diagnosis and
management in primary and secondary care (CG 108). National Institute for
Health and Clinical Excellence. Available online at
http://guidance.nice.org.uk/CG108/Guidance/pdf/English Accessed 2nd
August 2012.
3. Davis R, Heart failure: recent advances in diagnosis and management.
Prescriber 2012; 23 (13/14): 15-24
4. Hunt SA, Abraham WT et al, 2009 focused update incorporated into the
ACC/AHA 2005 guidelines for the diagnosis and management of heart failure
in adults: a report of the American College of Cardiology Foundation /
American Heart Association Task Force on Practice Guidelines. Circulation
2009; 119:e391-479
5. Changing Cardiovascular Health. National Cardiovascular Health Policy
2010-2019. Dept of Health & Children 2010. Available online at:
http://www.dohc.ie/publications/building_healthier_hearts.html. Accessed
22nd June 2011
6. Cheng s, Vasan RS, Advances in the Epidemiology of Heart Failure and Left
Ventricular Remodelling. Circulation 2011; 124:e516-e519
7. Lam C, Lyass A et al, Cardiac dysfunction and non-cardiac dysfunction as
precursors of heart failure with reduced and preserved ejection fraction in the
community. Circulation 2011; 124: 24-30
8. Klein L, Omnes Viae Romam Ducunt: Asymptomatic cardiac and non-cardiac
organ system dysfunction leads to heart failure. Circulation 2011; 124: 4-6
9. Congestive Heart Failure. NMIC 2006; 12: 2. Available online at
www.nmic.ie. Accessed 3rd August 2012
10. Lindenfeld J, Executive Summary: HFSA 2010 comprehensive heart failure
practice guideline. J Cardiac failure 2010; 16: 475-530
11. Witte K, Clark A, NYHA class 1 heart failure is not mild. Int J Cardiol.
2011;146:128-9
12. Davies EJ Moxham T et al, Exercise-based rehabilitation for heart failure.
Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.:
CD003331. DOI: 10.1002/14651858.CD003331.pub3
13. SPC Tritace. Available online at www.medicines.ie. Accessed 3rd August
2012
14. SPC Coversyl. Available online at www.medicines.ie. Accessed 3rd August
2012
15. SPC Zestril. Available online at www.medicines.ie. Accessed 3rd August
2012.
16. SPC Innovace. Available online at www.medicines.ie. Accessed 3rd August
2012
17. SPC Capoten. Available online at www.medicines.ie. Accessed 17th August
2012
18. SPC Cardicor. Available online at www.medicines.ie. Accessed 3rd August
2012
19. SPC Nebilet. Available online at www.medicines.ie. Accessed 3rd August
2012.

20. SPC Eucardic. Available online at www.medicines.ie. Accessed 3rd August

2012
21. SPC Lasix. Available online at www.medicines.ie. Accessed 17th
August 2012
22. SPC Burinex. Available online at www.medicines.ie. Accessed 20th August
2012
23. SPC Centyl K. Available online at www.medicines.ie. Accessed 20th August
2012
24. Flather M, Yusuf S et al, long-term ACE-inhibitor therapy in patients with
heart failure or left-ventricular dysfunction: a systematic overview of data
from individual patients. Lancet 2000; 355: 1575-81
25. Faris RF, Flather M et al, Diuretics for heart failure. Cochrane Database of
Systematic Reviews 2012, Issue 2. Art. No.: CD003838. DOI:
10.1002/14651858.CD003838.pub3
26. Heran BS, Musini VM et al, Angiotensin receptor blockers for heart failure.
Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.:
CD003040. DOI: 10.1002/14651858.CD003040.pub2
27. SPC Diovan. Available online at www.medicines.ie. Accessed 3rd August
2012
28. SPC Cozaar. Available online at www.medicines.ie. Accessed 3rd August
2012
29. SPC Atacand. Available online at www.medicines.ie. Accessed 3rd August
2012
30. SPC Aldactone. Available online at www.medicines.ie. Accessed 3rd August
2012
31. SPC Inspra. Available online at www.medicines.ie. Accessed 3rd August
2012
32. Butler J, Ezekowitz J et al, Update on Aldosterone Antagonists Use in Heart
Failure with Reduced left Ventricular Ejection Fraction: Heart Failure Society
of America Guidelines Committee. J Card Fail 2012; 18: 265-281
33. Pitt B et al. The effect of spironolactone on morbidity and mortality in patients
with severe heart failure. Randomised Aldactone Evaluation Study
Investigators. NEJM 1999; 341: 709-11
34. Pitt B et al. Eplernone, a selective aldosterone blocker, in patients with left
ventricular dysfunction after myocardial infarction. NEJM 2003; 348: 1309-21
35. Zannad F, McMurray JJ et al, Eplerenone in patients with systolic heart failure
and mild symptoms NEJM 2011; 364: 11-21
36. Hood Jr WB, Dans AL et al, Digitalis for treatment of heart failure in patients
in sinus rhythm. Cochrane Database of Systematic Reviews 2004, Issue 2. Art.
No.: CD002901. DOI: 10.1002/14651858.CD002901.pub2 [Review content
assessed as up-to-date: 12 April 2011]
37. SPC Procoralan. Available online at www.medicines.ie. Accessed 15th
August 2012
38. Swedberg K, Komajda M et al, Ivabradine and outcomes in chronic heart
frailure (SHIFT): a randomised placebo-controlled study lancet 2012; 376:
875-85
39. Lip G, Wrigley B, Pisters R, anticoagulation versus placebo for heart failure in
sinus rhythm. Cochrane Database of Systematic Reviews 2012, Issue 6. Art.
No.: CD003336. DOI: 10.1002/14651858.CD003336.pub2

40. SPC Cordarone. Available online at www.medicines.ie. Accessed 16th

August 2012.
41. Hypertension. NMIC 2011; 17: 5. Available online at www.nmic.ie. Accessed
3rd August 2012.