Heart Failure Medications for CKD Patients Based on Framingham Criteria
For patients with CKD and heart failure, initiate a foundational regimen of ACE inhibitor (or ARB if ACEi not tolerated), beta-blocker, and SGLT2 inhibitor, with diuretics for volume management, regardless of CKD stage down to eGFR ≥20 ml/min/1.73 m².
Initial Medication Algorithm
First-Line Therapy (Start All Three Simultaneously When Possible)
1. RAS Inhibition (ACEi or ARB)
- Start ACEi or ARB for heart failure with reduced ejection fraction, even in patients with CKD 1
- Use the highest approved dose tolerated to achieve proven trial benefits 1
- For lisinopril specifically: Start 5 mg daily in CKD with creatinine clearance >30 mL/min; reduce to 2.5 mg daily if creatinine clearance 10-30 mL/min 2
- Continue ACEi/ARB even when eGFR falls below 30 ml/min/1.73 m² 1
- Monitor BP, creatinine, and potassium within 2-4 weeks of initiation 1
2. Beta-Blockers
- Recommended for all stable heart failure patients (NYHA class II-IV) with reduced ejection fraction on standard therapy 1
- Beta-blockers reduce death in HF patients across all CKD stages, including dialysis 3, 4
- May reduce hospitalizations for heart failure (RR 0.67,95% CI 0.43-1.05) 5
- Mortality benefit in CKD patients (RR 0.69,95% CI 0.60-0.79) 5
3. SGLT2 Inhibitors
- Strongly recommended for heart failure irrespective of albuminuria level when eGFR ≥20 ml/min/1.73 m² 1
- Continue even if eGFR falls below 20 ml/min/1.73 m² after initiation, unless not tolerated 1
- Improved mortality and hospitalization in HFrEF with CKD stages 3-4 3
- The reversible eGFR decrease on initiation is not an indication to discontinue 1
Volume Management
Diuretics
- Loop diuretics preferred when GFR <30 ml/min; avoid thiazides at this level except synergistically with loop diuretics 1
- Always administer in addition to ACEi/ARB 1
- For insufficient response: increase dose, combine loop diuretics with thiazides, or administer loop diuretics twice daily 1
Second-Line Therapy
Mineralocorticoid Receptor Antagonists (MRA)
- Add aldosterone antagonist (spironolactone) for advanced heart failure (NYHA III-IV) to improve survival and morbidity 1
- For type 2 diabetes with CKD: consider nonsteroidal MRA if eGFR >25 ml/min/1.73 m², normal potassium, and persistent albuminuria despite maximum RASi dose 1
- Caution: May increase hyperkalaemia risk (RR 2.91,95% CI 2.03-4.17) 5
- Monitor potassium regularly after initiation 1
Critical Monitoring Parameters
When to Continue Despite Changes
Continue ACEi/ARB unless:
- Serum creatinine rises >30% within 4 weeks of initiation or dose increase 1
- Symptomatic hypotension occurs 1
- Uncontrolled hyperkalemia despite medical management 1
- eGFR <15 ml/min/1.73 m² with uremic symptoms 1
Hyperkalemia Management Strategy
Do not automatically stop RASi for hyperkalemia 1
- First attempt: potassium binders, dietary restriction, diuretics 1
- Reduce dose or discontinue only if hyperkalemia remains uncontrolled despite these measures 1
Common Pitfalls to Avoid
- Do not withhold ACEi/ARB/beta-blockers based solely on eGFR thresholds - these medications remain beneficial even with advanced CKD 1, 4
- Do not stop medications for modest creatinine elevation - only discontinue if rise >30% within 4 weeks 1
- Do not avoid SGLT2i due to initial eGFR dip - this is expected and reversible 1
- Do not combine ACEi + ARB + direct renin inhibitor - this triple combination is contraindicated 1
- Patients with CKD are systematically under-prescribed evidence-based HF therapies despite higher cardiovascular risk 6
Additional Considerations
Cardiovascular Risk Reduction
- Statin therapy recommended for adults ≥50 years with eGFR <60 ml/min/1.73 m² 1
- Low-dose aspirin for secondary prevention in established ischemic cardiovascular disease 1
Temporary Withholding
- Consider withholding SGLT2i during prolonged fasting, surgery, or critical illness (ketosis risk) 1