CHF 2: medications

Tina revisits ACEI, ARB, BB, and Thiazides, which were covered previously with the hypertension episodes, and introduces a few new medications as well:

  • Mineralocorticoid Receptor Antagonists: spironolactone and eplerenone
  • Loop diuretic: furosemide
  • Digoxin
  • Vasodilators: hydralazine and isosorbite dinitrate

For a quick summary of the CCS 2013 recommendations:

ACE inhibitors:

  • all asymptomatic patients with an EF < 35%
  • all symptomatic HF patients and EF < 40%


  • if intolerant to ACEI
  • add to ACEI if intolerant or contraindicated for BB
  • add to ACEI and BB if NYHA class II-IV HF and EF ≤ 40% deemed at increased risk of HF events


  • all HF patients with an EF ≤ 40%
  • initiated at a low dose and titrated to the target dose or maximal tolerated dose


  • patients > 55 years with mild to moderate HF during standard HF treatments with EF ≤ 30% (or ≤ 35% if QRS duration > 130 ms) and recent (6 months) hospitalization for CV disease or
  • with elevated BNP or NT-proBNP levels
  • after an MI with EF ≤ 30% and HF or
  • EF ≤ 30% alone in the presence of diabetes
  • EF < 30% and severe chronic HF (NYHA IIIB-IV) despite optimization of other recommended treatments


  • for congestive symptoms
  • When acute congestion is cleared, the lowest dose should be used that is compatible with stable signs and symptoms
  • persistent volume overload despite optimal medical therapy and increases in loop diuretics, cautious addition of a second diuretic (a thiazide or low dose metolazone) may be considered as long as it is possible to closely monitor morning weight, renal function, and serum potassium


  • patients in sinus rhythm who continue to have moderate to severe symptoms, despite optimized HF therapy
  • patients with chronic atrial fibrillation (AF) and poor control of ventricular rate

Isosorbide dinitrate and hydralazine:

  • black Canadians with HF-REF
  • non-black HF patients unable to tolerate an ACE inhibitor or ARB

Drug information from:

  • Drug monographs
  • CPS:
  • Therapeutic Choices:
  • Rx Files: