From the Guidelines
Medication dosing in chronic heart failure typically follows a stepwise approach starting with low doses that are gradually increased to target doses as tolerated. The most recent and highest quality study, 1, recommends that ACE inhibitors should be started at low doses and titrated upward to doses shown to reduce the risk of cardiovascular events in clinical trials. Some key medications and their dosages include:
- ACE inhibitors (such as enalapril 2.5-20mg twice daily or lisinopril 10-40mg daily)
- ARBs (such as losartan 25-150mg daily)
- Beta-blockers (such as carvedilol 3.125-25mg twice daily or metoprolol succinate 12.5-200mg daily)
- Mineralocorticoid receptor antagonists like spironolactone (25-50mg daily) or eplerenone (25-50mg daily)
- Loop diuretics such as furosemide (20-240mg daily)
- SGLT2 inhibitors like dapagliflozin (10mg daily) and empagliflozin (10mg daily). Doses should be titrated slowly over weeks to months while monitoring blood pressure, heart rate, renal function, and electrolytes, as recommended by 1 and 1. Patients should be educated about monitoring daily weights, limiting sodium intake, and recognizing worsening symptoms that require medical attention, as suggested by 1 and 1. These medications work synergistically to reduce cardiac workload, prevent adverse remodeling, and improve survival in heart failure patients. It is essential to note that the approach to treating heart failure should prioritize achieving target doses of evidence-based medications, as discussed in 1 and 1.
From the FDA Drug Label
- 2 Heart Failure The recommended starting dose for lisinopril tablets, when used with diuretics and (usually) digitalis as adjunctive therapy for systolic heart failure, is 5 mg once daily. The recommended starting dose in these patients with hyponatremia (serum sodium < 130 mEq/L) is 2. 5 mg once daily. Increase as tolerated to a maximum of 40 mg once daily.
The dosage guidelines for lisinopril in patients with chronic heart failure are as follows:
- The recommended starting dose is 5 mg once daily when used with diuretics and digitalis as adjunctive therapy for systolic heart failure.
- In patients with hyponatremia, the recommended starting dose is 2.5 mg once daily.
- The dose can be increased as tolerated to a maximum of 40 mg once daily 2.
From the Research
Dosage Guidelines for Chronic Heart Failure
The dosage guidelines for medications in chronic heart failure are as follows:
- Angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril, should be used in high doses (32.5 to 35mg, administered once daily) to reduce the risk of major clinical events in patients with heart failure 3, 4, 5.
- The use of high doses of ACE inhibitors has been shown to be more effective than low doses in reducing the risk of death or hospitalization for any reason and hospitalizations for heart failure 3, 5.
- Beta blockers should be used in target doses (≥ 95% of the respective published guideline-recommended dose) to improve survival in patients with chronic systolic heart failure (CHF) 6.
- Angiotensin II receptor blockers (ARBs) can be used if patients are intolerant to ACE inhibitors, and sacubitril/valsartan may be used instead of an ACE inhibitor or ARB in patients with chronic symptomatic HFrEF class II or III 7.
- Aldosterone antagonists, such as spironolactone or eplerenone, can be added in selected patients with class II-IV HF who can be carefully monitored for renal function and potassium concentration 7.
Key Considerations
- The dosage of medications should be titrated to the maximum tolerated dose to achieve optimal benefits 4.
- Patients with chronic heart failure should be monitored regularly for adverse events, such as hypotension and renal dysfunction, and the dosage of medications should be adjusted accordingly 3, 4, 5.
- The use of combination therapy, including ACE inhibitors, beta blockers, and ARBs, can provide additional benefits in reducing morbidity and mortality in patients with chronic heart failure 7.