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Management of Chronic Left Ventricular Systolic Heart Failure – Adult – Inpatient/Ambulatory

Management of Chronic Left Ventricular Systolic Heart Failure – Adult – Inpatient/Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Cardiovascular


1
Management of Chronic Left Ventricular
Systolic Heart Failure – Adult –
Inpatient/Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
Table of Contents
EXECUTIVE SUMMARY ........................................................................................................... 3
Management of Risk Factors .............................................................................................................. 3
Non-Pharmacological Management .................................................................................................... 3
Medications ......................................................................................................................................... 7
Laboratory Tests ............................................................................................................................... 10
Referral to Electrophysiology ............................................................................................................ 10
Referral to Cardiology ....................................................................................................................... 10
SCOPE .....................................................................................................................................12
METHODOLOGY .....................................................................................................................13
INTRODUCTION ......................................................................................................................14
RECOMMENDATIONS .............................................................................................................14
UW HEALTH IMPLEMENTATION ............................................................................................15
APPENDIX A. BETA BLOCKER EQUIVALENCY DOSING FOR PATIENTS WITH HEART
FAILURE5-14 ..............................................................................................................................18
REFERENCES .........................................................................................................................19
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2015CCKM@uwhealth.org

2
CPG Contact for Content:
Name: Maryl Johnson, MD- Medicine- Cardiology
Phone Number: (608) 263-0080
Email Address: mrj@medicine.wisc.edu
CPG Contact for Changes:
Name: Lindsey Spencer, MS- Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org
Guideline Author(s):
American College of Cardiology Foundation/American Heart Association (ACCF/AHA)
Coordinating Team Members:
Peter Rahko, MD- Medicine- Cardiology
Shahab Akhter, MD- Surgery- Cardiothoracic
Lucian Lozonschi, MD- Surgery- Cardiothoracic
Nicole Bonk, MD- Urgent Care- Family Medicine- General
Irene Hamrick, MD- Family Medicine- General
Michael Thom, MD- Medicine- Internal Medicine- General
Peter Gill, MD- Medicine- Hospitalist
Margaret Murray, DNP- Surgery- Cardiothoracic
Cindy Gaston, PharmD, BCPS- Drug Policy Program
Anne Rose, PharmD, BCPS- Pharmacy- Inpatient Services
Jennifer Schauer, PharmD- Pharmacy- Unity Pharmacy Program
Peter Rusch, RT- Respiratory Therapy
Vonda R. Shaw, MS, MPH- Preventive Cardiology and Heart Station Manager
Deana Jansa, MBA/HCM, BSN, RN-BC- Clinics- Administration
Jill Lindwall, MSN, RN- Clinic Management- General
Kristen Sipsma, MPH- Center for Clinical Knowledge Management (CCKM)
Jennifer Grice, PharmD, BCPS- Center for Clinical Knowledge Management (CCKM)
Review Individuals/Bodies:
Mark Micek, MD- Medicine- Internal Medicine- General
Teresa Darcy, MD- Pathology- General
Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council (12/17/2015)
Release Date: December 2015 | Next Review Date: December 2017
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2015CCKM@uwhealth.org

3
Executive Summary
Guideline Overview
UW Health has agreed to endorse and adopt the 2013 ACCF/AHA Guidelines for the
Diagnosis and Management of Heart Failure in Adults.1
Key Revisions (2016 Periodic Review)
1. Added criteria for cardiac rehabilitation referral (page 3).
2. Adapted algorithm for guideline-directed medical therapy (page 6).
3. Added recommendations for sacubitril/valsartran and ivabradine (pages 7-8, 14).
4. Added beta blocker dosing equivalency table (Appendix A).
Key Practice Recommendations
MANAGEMENT OF RISK FACTORS
1. Control hypertension and lipid disorders according to current guidelines.1 (AHA Class I,
Level of Evidence A)
2. Avoid tobacco use or exposure.1 (AHA Class I, Level of Evidence C)
3. Control or avoid obesity, diabetes mellitus, and use of known cardiotoxic agents.1
(AHA Class I, Level of Evidence C)
NON-PHARMACOLOGICAL MANAGEMENT
1. Patients with HFrEF should receive education to facilitate self-care.1 (AHA Class I,
Level of Evidence B)
2. Exercise training (or regular physical activity) is recommended in patients who are
able to participate.1 (AHA Class I, Level of Evidence A)
3. Cardiac rehabilitation can be useful in clinically stable heart failure patients.1 (AHA
Class IIa, Level of Evidence B) Non-Medicare insurers may cover the service based upon
medical necessity and will be evaluated by staff upon referral.
The following enrollment criteria are required prior to participation:
ξ Ventricular ejection fraction < 35% (measured within the last 12 months)
ξ New York Heart Association (NYHA) Class II-III symptoms despite being on
optimal medical therapy for at least 6 weeks
ξ Clinical stability, defined as not having a recent (< 6 weeks) or planned (< 6
months) major cardiovascular hospitalization or procedure
ξ Referral by a cardiologist directly involved with the patient’s care. Direct
referrals from non-cardiology physicians will be reviewed by the Preventive
Cardiology Medical Director.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
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4
4. Sodium restriction is reasonable to reduce congestive symptoms in patients who are
symptomatic.1 (AHA Class IIa, Level of Evidence C)
5. Fluid restriction (1.5-2 L/day) is reasonable in stage D, especially in patients with
hyponatremia, to reduce congestive symptoms.1 (AHA Class IIa, Level of Evidence C) As a
patient's heart failure starts to decompensate, thirst is stimulated and fluid restriction
may be provided to reduce the risk of fluid overload.
6. Effective systems of care coordination, with special attention to care transitions,
should be deployed for every patient with chronic HFrEF that facilitate and ensure
effective care that is designed to achieve guideline-directed medical and device
therapy (GDMT) and prevent hospitalization.1 (AHA Class I, Level of Evidence B)
7. Palliative care should be considered for patients with advanced HF, especially those
who are not candidates for heart transplantation or mechanical circulatory support.1
(AHA Class I, Level of Evidence B)
Stages of heart failure (HF) and recommended treatment are shown in Figures 1- 2.
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority
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5
FIGURE 1. Stages in the Development of HF and Recommended Therapy by Stage1
ACEI indicates angiotensin-converting enzyme inhibi-tor; AF, atrial ἀbrillation; ARB, angiotensin-receptor blocker; CAD, coronary artery disease; CRT, cardiac resynchronization therapy; DM, diabetes mellitus;
EF, ejection fraction; GDMT, guideline-directed medical therapy; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; HRQOL, health-
related quality of life; HTN, hypertension; ICD, implantable cardioverter-defibrillator; LV, left ventricular; LVH, left ventricular hypertrophy; MCS, mechanical circulatory support; and MI, myocardial infarction.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: CCKM@uwhealth.org 12/2015

6
FIGURE 2. Stage C HFrEF Guideline-Directed Medical Therapy
HFrEF Stage C NYHA Class I-IV
Treatment:
AHA Class I, LOE A
ACEI or ARB AND
Beta Blocker
For persistently
symptomatic African
Americans,
NYHA Class III-IV
For NYHA class II-IV
patients. Provided
estimated creatinine
clearance > 30 mL/min
and K+ < 5.0 mEq/dL
For all volume
overload, NYHA Class
II-IV patients
For NYHA Class II-III
patients with NSR,
HR > 70 bpm
For NYHA Class II-IV
patients
Transition from
ACEI/ARB
UW Health Class IIa, LOE B
Sacubitril/valsartan
Add
AHA Class I, LOE A
Aldosterone
Antagonist
ACEI indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin-receptor blocker; AHA, American Heart Association; HFrEF, heart failure with reduced ejection
fraction; Hydral-Nitrates, hydralazine and isosorbide dinitrate; LOE, Level of Evidence; NSR, normal sinus rhythm; NYHA, New York Association
AHA Class I, LOE A
Hydral-Nitrates
AHA Class I, LOE C
Loop Diuretics
UW Health Class IIa, LOE B
Ivabradine
AddAddAdd
Figure adapted from the 2013 ACCF/AHA Guideline.1-3
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
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MEDICATIONS
In patients requiring hospitalization during chronic maintenance guideline directed
medical therapy for HFrEF, the medical therapy should be continued during the
hospitalization in the absence of hemodynamic instability or contraindications. If the
therapy requires a decrease or discontinuation during the hospital stay, the therapy
should be resumed at or following hospital discharge as the patient's condition allows.
1. Angiotensin-converting enzyme inhibitors (ACEI) should be prescribed unless
contraindicated.1 (AHA Class I, Level of Evidence A) However, sacubitril/valsartan could
be prescribed in preference to ACEI (see below).
2. An angiotensin-receptor blocker (ARB), preferably candesartan or valsartan, should
be prescribed in ACEI intolerant patients, unless contraindicated.1 (AHA Class I, Level of
Evidence A)
3. Contraindications to BOTH ACEIs and ARBs must be documented individually. Such
a patient should be prescribed the combination of hydralazine/nitrates.
4. One of the beta blockers proven to reduce mortality in HFrEF (carvedilol, metoprolol
succinate, or bisoprolol) should be prescribed to patients with HFrEF.1 (AHA Class I,
Level of Evidence A) If a beta blocker is not prescribed, a contraindication must be
documented.
5. Sacubitril/valsartan has demonstrated a survival benefit compared to enalapril in
patients on GDMT to reduce the risk of cardiovascular death and hospitalization for
heart failure in patients with chronic heart failure (NYHA Class II-IV) and reduced
ejection fraction. It is recommended in patients on guideline-directed medications at
a dose equivalent to at least 10 mg of enalapril daily and NYHA Class II-IV and heart
failure hospitalization within the last year.3 (UW Health Class IIa, Level of Evidence B)
Patients on GMDT should be transitioned off of the ACE-I (at least 36 hour washout)
prior to initiation, as this medication should not be used in conjunction with ACE-I or
additional ARBs. Beta blocker therapy should be continued on the maximum
tolerated dose. The most common side effects are hyperkalemia, hypotension, renal
impairment, dizziness. Additional valsartan should not be prescribed.
6. An aldosterone receptor antagonist (ARA) should be prescribed, unless
contraindicated, in high risk patients with New York Heart Association (NYHA) Class
II HF (prior hospitalization or elevated natriuretic peptide levels) and in all patients
with NYHA Class III or IV HF, if the creatinine is < 2.5 mg/dL in men or < 2.0 mg/dL
in women and potassium < 5.0 mEq/L.1 (AHA Class I, Level of Evidence A) When ARAs
are prescribed, renal function and potassium levels must be checked weekly until
stable, then every three months.
7. The combination of hydralazine and isosorbide dinitrate is recommended to reduce
mortality in African Americans with NYHA Class III-IV heart failure on optimal ACEI
and beta-blocker therapy.1 (AHA Class I, Level of Evidence A)
8. Ivabradine is reasonable in patients with stable, symptomatic heart failure in normal
sinus rhythm on guideline-directed medications (e.g., ACE, ARB, beta blocker) at the
guideline-directed or highest tolerated dose, yet with resting heart rate > 70 bpm.2
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
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8
(UW Health Class IIa, Level of Evidence B) The most common side effects include
bradycardia, hypertension, atrial fibrillation, and temporary vision disturbances
(flashes of light). Hospital admission for heart failure and heart failure deaths are
significantly reduced by use of ivabradine in those patients described above.
9. Loop diuretics are recommended for treatment of volume overload to improve
symptoms.1 (AHA Class I, Level of Evidence C) Appropriate dosing should result in a
compensated patient with no signs and symptoms of volume overload.
10. Digoxin should be reserved for patients with persistent symptoms and
hospitalizations due to heart failure.1 (AHA Class IIa, Level of Evidence B) Low doses
should be prescribed, and the blood concentration should not exceed 1.0 ng/mL.
11. Medications to AVOID1:
ξ Nonsteroidal anti-inflammatory drugs (NSAIDs) (AHA Class III, Level of Evidence B)
ξ Most antiarrhythmics, except amiodarone (AHA Class III, Level of Evidence B)
ξ Nondihydropyridine calcium channel blockers with negative inotropic effects,
such as diltiazem or verapamil. The dihydropyridine calcium channel blocker
amlodipine has been shown to be safe, but not beneficial, in patients with
heart failure and EF < 30%. (AHA Class III, Level of Evidence C)
ξ Thiazolidinediones (e.g., rosiglitazone, pioglitazone) (AHA Class III, Level of
Evidence B)
ξ Alpha blocking drugs used to treat hypertension (e.g., prazosin, doxazosin)
are associated with increased mortality in heart failure with LV systolic
dysfunction, and alternative therapy should be sought.
A summary of drugs commonly used for Stage C HFrEF are shown in Table 1 below1,4:
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
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TABLE 1. Drugs Used in Stage C HFrEF
Drug Initial Daily Dose(s) Maximum Dose(s) Mean Dose Achieved in Clinical Trials1
ACE inhibitors
Captopril 6.25 mg 3 times 50 mg 3 times 122.7 mg/day
Enalapril 2.5 mg twice 10 to 20 mg twice 16.6 mg/day
Lisinopril 2.5 to 5 mg 20 to 40 mg once 32.5 to 35 mg/day
Fosinopril 5 to 10 mg once 40 mg once N/A
Perindopril 2 mg once 8 to 16 mg once N/A
Quinapril 5 mg twice 20 mg twice N/A
Ramipril 1.25 to 2.5 mg once 10 mg once N/A
Trandolapril 1 mg once 4 mg once N/A
ARBs
Candesartan 4 to 8 mg once 32 mg once 24 mg/day
Losartan 25 to 50 mg once 50 to 150 mg once 129 mg/day
Valsartan 20 to 40 mg twice 160 mg twice 254 mg/day
Beta Blockers
Bisoprolol 1.25 mg once 10 mg once 8.6 mg/day
Carvedilol 3.125 mg twice 50 mg twice 37 mg//day
Carvedilol CR 10 mg once 80 mg once N/A
Metoprolol succinate
ER (metoprolol CR/XL) 12.5 to 25 mg once 200 mg once 159 mg/day
Aldosterone antagonists
Spironolactone 12.5 to 25 mg once 25 mg once or twice 26 mg/day
Eplerenone 25 mg once 50 mg once 42.6 mg/day
Hydralazine and isosorbide dinitrate
Fixed-dose
combination
37.5 mg hydralazine/20 mg
isosorbide dinitrate 3 times
daily
75 mg hydralazine/40 mg
isosorbide dinitrate 3 times
daily
~175 mg hydralazine/90
mg isosorbide dinitrate
daily
Hydralazine and
isosorbide dinitrate
Hydralazine: 25 to 50 mg, 3
or 4 times daily and
isosorbide dinitrate: 20 to 30
mg 3 or 4 times daily
Hydralazine: 300 mg daily
in divided doses and
isosorbide dinitrate: 120
mg daily in divided doses
N/A
Miscellaneous
Ivabradine2 5 mg twice 7.5 mg twice 12.9 mg/day
Sacubitril/valsartan3 49/51 mg twice 97/103 mg twice 375 mg
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
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LABORATORY TESTS
1. Initial laboratory evaluation of patients presenting with heart failure should include
complete blood count, urinalysis, serum electrolytes (including calcium and
magnesium), BUN, serum creatinine, glucose, fasting lipid profile, liver function
tests, and TSH.1 (AHA Class I, Level of Evidence C)
2. Serial monitoring, when indicated, should include serum electrolytes and renal
function.1 (AHA Class I, Level of Evidence C) Patients with heart failure should have BUN,
serum creatinine and potassium monitored on a regular basis (at least every 6
months or more frequently if clinically unstable).
REFERRAL TO ELECTROPHYSIOLOGY
(For Consideration of Device Therapy [AICD &/or Cardiac Resynchronization Therapy] if LVEF ≤ 35%)
1. Implantable cardiac defibrillator (ICD) implantation
ξ ICD therapy for primary prevention of sudden cardiac death is recommended
in patients with nonischemic dilated cardiomyopathy or ischemic heart
disease at least 40 days post-MI with LVEF < 35% and NYHA class II or III
symptoms on guideline directed medical therapy who have reasonable
expectation of meaningful survival for > 1 year.1 (AHA Class I, Level of Evidence A)
ξ ICD therapy is recommended for primary prevention of sudden cardiac death
in patients at least 40 days post-MI, with LVEF < 30%, and NYHA class I
symptoms while receiving guideline directed medical therapy who have
reasonable expectation of meaningful survival for > 1 year.1 (AHA Class I, Level
of Evidence B)
2. ICD implantation is of uncertain benefit in patients with a high risk of non sudden
death as predicted by frequent hospitalizations, advanced frailty, dementia, or
comorbidities such as systemic malignancy or severe renal dysfunction.1 (AHA Class
IIb, Level of Evidence B) Cardiac resynchronization therapy (CRT) – see Figure 3.4
REFERRAL TO CARDIOLOGY
1. Failure to tolerate guideline-directed medical therapy (GDMT).
2. Persistent volume overload despite therapy with diuretics, leading to repeated
hospitalizations.
Companion Documents
1. Beta Blocker Equivalency Dosing Table
Related UW Health Clinical Practice Guidelines
1. Atrial Fibrillation Management – Adult – Inpatient/Ambulatory
2. Management of Non-ST Elevation Acute Coronary Syndromes – Adult –
Inpatient
3. Mechanical Circulatory Device (MCD) – Adult – Inpatient/Ambulatory
4. Hypertension – Adult – Inpatient/Ambulatory
5. Secondary Prevention of ASCVD – Adult – Inpatient/Ambulatory
6. Standards of Medical Care in Diabetes – Pediatric/Adult – Inpatient/Ambulatory
7. Obesity – Adult - Ambulatory
8. Tobacco Cessation – Adult/Pediatric – Inpatient/Ambulatory
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
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FIGURE 3. Indications for CRT therapy algorithm
CRT indicates cardiac resynchronization therapy; CRT-D, cardiac resynchronization therapy-defibrillator; GDMT, guideline-directed medical therapy; HF, heart failure; ICD, implantable
cardioverter-defibrillator; LBBB, left bundle-branch block; LVEF, left ventricular ejection fraction; MI, myocardial infarction; and NYHA, New York Heart Association.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
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Scope
Disease/Condition(s): Heart Failure
Clinical Specialty: Cardiology, Primary Care, Cardiothoracic Surgery, Pharmacy,
Laboratory, Nursing
Intended Users: Physicians, Advance Practice Providers, Nurses (RN Care
Coordinators, RN, LPN, MA), Pharmacists
Objective(s): To assist clinicians in clinical decision making by describing a range of
generally acceptable approaches to the diagnosis, management and prevention of heart
failure.
Target Population: Patients age 18 years or older with reduced left ventricular heart
function. This guideline does not include recommendations for congenital heart lesions
in adults.
Interventions and Practices Considered:
ξ Guideline-directed medical and device therapy (GDMT)
ξ Management of comorbidities
ξ Patient/family education
ξ Physical activity/cardiac rehabilitation
ξ Mechanical circulatory support
ξ Coronary artery revascularization via coronary artery bypass graft (CABG) or
percutaneous/transcatheter intervention
Major Outcomes Considered:
ξ Reduced mortality
ξ Increased quality of life
Guideline Metrics:
1. Number of deaths per 100 discharges with principal diagnosis code of CHF (AHRQ – IQI 16)
2. All discharges of age 18 years and older with ICD-9-CM principal diagnosis code for heart
failure (AHRQ – IQI 8)
3. Percentage of patients aged 18 years or older with a diagnosis of heart failure with a current
or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker
therapy either within a 12 month period when seen in the outpatient setting OR at each
hospital discharge (ACO-MSSP)
4. Percentage of patients aged 18 years or older with a diagnosis of heart failure with a current
or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed a ACE-I/ARB
either within a 12 month period when seen in the outpatient setting OR at each hospital
discharge (CPG Workgroup-derived)
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13
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches were conducted to collect evidence for review, in addition
to review of the 2013 ACC/AHA guideline. Expert opinion and clinical experience were
also considered during review of the evidence.
Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by the
ACC/AHA and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup
were reviewed and approved by other stakeholders or committees (as appropriate).
Methods Used to Assess the Quality and Strength of the
Evidence/Recommendations:
Recommendations developed by external organizations (e.g., ACC/AHA) maintained
the evidence grade assigned within the original source document and were adopted for
use at UW Health. Internally developed recommendations were evaluated by the
guideline workgroup using the ACC/AHA grading scheme.
Rating Scheme for the Strength of the Evidence/Recommendations:
A modified Grading of Recommendations, Assessment, Development and Evaluation
(GRADE) scheme developed by the American Heart Association and American College
of Cardiology
(see Figure 4)
was used to
grade each
recommendation.
Figure 4.
ACC/AHA
Grading Scheme
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Introduction
Despite improvements in medicine, the absolute mortality rates for heart failure remain
at approximately 50% within five years of initial diagnosis.1 In addition, the primary
diagnosis for over 1 million inpatient admissions annually is heart failure.1 The 2013
ACCF/AHA Guidelines are intended to provide clinicians with generally acceptable
approaches to the diagnosis, management, and prevention of heart failure.
Recommendations
UW Health endorses the recommendations outlined within the 2013 ACCF/AHA
Guidelines for the Diagnosis and Management of Heart Failure in Adults located online
at http://circ.ahajournals.org/content/128/16/e240.extract.1 These recommendations are
for heart failure with reduced ejection fraction (HFrEF) defined as a left ventricular
ejection fraction (LVEF) of < 40%. If clinically appropriate, these guidelines can be used
with patients who have an LVEF between 41 to 50%.
In addition to those recommendations found within the ACCF/AHA Guideline, the
following supplementary statements were developed by UW Health as a result of the
recent FDA approval of two medications:
 Sacubitril/valsartan has demonstrated a survival benefit compared to enalapril in
patients on guideline-directed medical therapy (GDMT) to reduce the risk of
cardiovascular death and hospitalization for heart failure in patients with chronic
heart failure (NYHA Class II-IV) and reduced ejection fraction. It is recommended
in patients on guideline-directed medications at a dose equivalent to at least 10
mg of enalapril daily and NYHA Class II-IV and heart failure hospitalization within
the last year.3 (UW Health Class IIa, Level of Evidence B) Patients on GMDT should be
transitioned off of the ACE-I (at least 36 hour washout) prior to initiation, as this
medication should not be used in conjunction with ACE-I or additional ARBs.
Beta blocker therapy should be continued on the maximum tolerated dose. The
most common side effects are hyperkalemia, hypotension, renal impairment,
dizziness. Additional valsartan should not be prescribed.
 Ivabradine is reasonable in patients with stable, symptomatic heart failure in
normal sinus rhythm on guideline-directed medications (e.g., ACE, ARB, beta
blocker) at the guideline-directed or highest tolerated dose, yet with resting heart
rate > 70 bpm.2 (UW Health Class IIa, Level of Evidence B) The most common side
effects include bradycardia, hypertension, atrial fibrillation, and temporary vision
disturbances (flashes of light). Hospital admission for heart failure and heart
failure deaths are significantly reduced by use of ivabradine in those patients
described above.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2015CCKM@uwhealth.org

15
UW Health Implementation
Potential Benefits:
ξ Improved patient outcomes, including reduced mortality and increased quality of life
ξ Decreased hospital readmissions
Potential Harms:
ξ Medications such as NSAIDs, most antiarrhythmic drugs, and most calcium channel
blocking drugs could be indicated for other conditions, while contraindicated for heart
failure.
Pertinent UW Health Policies & Procedures
None.
Patient Resources
1. Health Factors for You #3072- Heart Failure Packet
a. Health Facts for You #6087- Congestive Heart Failure
b. Health Facts for You #5817- Your Risk of Heart and Vascular Disease
c. Health Facts for You #5818- About Plaque
d. Health Facts for You #6094- Weight and Vital Signs Log
e. Health Facts for You #180- Sodium
f. Health Facts for You #203- Tips for Healthy Eating Out
g. Health Facts for You #302- How to Read Food Labels
2. Health Facts for You #3199- Heart Failure (KAB) Packet
a. Health Facts for You #6087- Congestive Heart Failure
b. Health Facts for You #7810- Heart Failure Zones
c. Health Facts for You #180- Sodium
d. Health Facts for You #5528- Sodium Content of Common Foods
e. Health Facts for You #302- How to Read Food Labels
f. Health Facts for You #203- Tips for Healthy Eating Out
3. Health Facts for You #6154- Congestive Heart Failure for VAD Patients
4. Health Facts for You #6885- Heart Failure and Depression
5. Health Facts for You #7727- Cardiac Rehabilitation for Heart Failure
6. Health Facts for You #4951- The Heart Transplant Process
7. Health Facts for You #6546- Waiting for your Heart Transplant
8. Healthwise: ACE Inhibitors
9. Healthwise: ACE Inhibitors: General Info
10. Healthwise: ACE Inhibitors: Heart Failure: General Info
11. Healthwise: ARBs: General Info
12. Healthwise: Beta-Blockers
13. Healthwise: Heart Failure
14. Healthwise: Heart Failure: General Info
15. Healthwise: Heart Failure Zones: General Info
16. Healthwise: Heart Failure: Advance Care Planning
17. Healthwise: Heart Failure: Arrhythmias
18. Healthwise: Heart Failure: Avoiding Triggers
19. Healthwise: Heart Failure: Limiting Sodium and Fluids
20. Healthwise: Heart Failure: Managing Other Conditions
21. Healthwise: Heart Failure: Medicines
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16
22. Healthwise: Heart Failure: Medicines to Avoid
23. Healthwise: Heart Failure: Oxygen Therapy
24. Healthwise: Heart Failure: Self-Care: General Info
25. Healthwise: Heart Failure: Sleep Apnea
26. Health Information: Heart Failure
27. Health Information: Heart Failure and Sexual Activity
28. Health Information: Heart Failure and Sleep Problems
29. Health Information: Heart Failure Complications
30. Health Information: Heart Failure Stages
31. Health Information: Heart Failure Symptoms
32. Health Information: Heart Failure Types
33. Health Information: Heart Failure: Activity and Exercise
34. Health Information: Heart Failure: Avoiding Colds and Flu
35. Health Information: Heart Failure: Avoiding Medications That Make Symptoms Worse
36. Health Information: Heart Failure: Avoiding Triggers for Sudden Heart Failure
37. Health Information: Heart Failure: Checking Your Weight
38. Health Information: Heart Failure: Compensation by the Heart and Body
39. Health Information: Heart Failure: Disease Management Programs
40. Health Information: Heart Failure: Eating a Healthy Diet
41. Health Information: Heart Failure: Eating Out on a Low Salt Diet
42. Health Information: Heart Failure: Less Common Symptoms
43. Health Information: Heart Failure: Should I Get a Pacemaker (Cardiac Resynchronization
Therapy)?
44. Health Information: Heart Failure: Should I Get an Implantable Cardioverter-Defibrillator
(ICD)?
45. Health Information: Heart Failure: Taking Medicines Properly
46. Health Information: Heart Failure: Tips for Caregivers
47. Health Information: Heart Failure: Tips for Easier Breathing
48. Health Information: Heart Failure: Watching Your Fluids
Implementation Plan/Tools
1. Guideline will be housed on U-Connect in a dedicated folder for CPGs.
2. Release of the guideline will be advertised in the Clinical Knowledge Management
Corner within the Best Practice newsletter.
3. Links to this guideline will be updated and/or added in appropriate Health Link or
equivalent tools, including:
Order Sets/Smart Sets
CHF Office Visit [3148]
IP – Heart Failure – Adult – Admission [688]
IP – Heart Failure – Adult – Discharge [1411]
IP – Cardiology – Adult – Discharge [3328]
IP – Cardiac Surgery – Adult – Preoperative [2701]
IP – Pre Ventricular Assist Device – Adult – Admission [5851]
IP – Contrast Induced Nephropathy Prophylaxis – Heart Failure/Fluid Volume Overload [1342]
Best Practice Alerts
UWIP BPA Heart Failure ACE-I/ARB [2586; 3000583; 1896]
UWIP BPA Heart Failure ACE-I/ARB/BB [3000575; 3000584; 1897; 1898]
UWIP BPA Heart Failure Beta Blocker [2413; 3000585; 3000586; 1899; 1900]
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2015CCKM@uwhealth.org

17
UWOP BPA Heart Failure ACE-I/ARB [2328]
UWOP BPA Heart Failure BB [2334]
Delegation Protocols
Heart Failure Lab Ordering – Adult – Ambulatory [77]
Heart Failure Medication Titration – Adult – Ambulatory [82]
e-Consults
eConsult to Cardiology- Heart Failure [5625]
Care Plans
Heart Failure- Adult IPOC [508]
Heart Failure- Geriatric IPOC [509]
Coping, Ineffective – Heart Failure – Adult [505]
Knowledge, Deficient – Heart Failure – Adult [504]
Fluid/Electrolyte Imbalance – Heart Failure – Adult [506]
Gas Exchange, Impaired – Heart Failure – Adult [507]
Miscellaneous
Standard Order Group for All Discharge Order Sets [OSQ 190359]
Problem List Smart Form (Documentation of contraindications to GDMT)
Heart Failure Registry
Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach
for most patients. It is not intended to replace a clinician’s judgment or to establish a
protocol for all patients. It is understood that some patients will not fit the clinical
condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2015CCKM@uwhealth.org

18
Appendix A. Beta Blocker Equivalency Dosing for Patients
with Heart Failure5-14
NOTE: Conversion carvedilol or metoprolol succinate should be made in patients with HFrEF, as these are the
medications most commonly used in the U.S. that have been found to be effective in the treatment of HFrEF.
Current Prescription* CONVERSION
Carvedilol
Metoprolol
succinate ER
Atenolol 50 mg daily 12.5 mg BID 100 mg daily
100 mg daily 25 mg BID+ 200 mg daily
Labetalol
100 mg BID 12.5 mg BID 100 mg daily
200-400 mg BID 25 mg BID+ 200 mg daily
Metoprolol
tartrate
25-50 mg BID 12.5 mg BID 100 mg daily
100-200 mg BID 25 mg BID+ 200 mg daily
Nadolol
40 mg daily 3.125 mg - 6.25 mg BID 25 mg daily
80 mg daily 12.5 mg BID 100 mg daily
240-320 mg daily 25 mg BID+ 200 mg daily
Propranolol
40 mg BID or 80 mg of ER
daily
12.5 mg BID 100 mg daily
60-120 mg BID or 120-160
mg of ER daily 25 mg BID+ 200 mg daily
Timolol 10 mg BID 12.5 mg BID 100 mg daily
10-30 mg BID 25 mg BID+ 200 mg daily
Acebutolol 200 mg BID or 400 mg daily 12.5 mg BID 100 mg daily
200-400 mg BID 25 mg BID+ 200 mg daily
Pindolol 5 mg BID 12.5 mg BID 100 mg daily
30 mg BID 25 mg BID+ 200 mg daily
*Doses provided are approximate. Lower initial doses may be chosen at the provider’s discretion; +Carvedilol 50 mg
BID if ≥ 85 kg; BID: twice daily; ER: extended release
Both carvedilol and metoprolol succinate are off-patent and available in generic form. Because
of manufacturing issues with generic metoprolol succinate, carvedilol tends to be lower in cost
at this time.
Once the conversion is made to a guidelines-approved beta blocker, attempts should be made
to uptitrate to the goal doses shown to have mortality benefit in trials of heart failure patients
with reduced ejection fraction. For carvedilol, this dose is 25 mg bid if < 85 kg, 50 mg BID if ≥
85 kg. For metoprolol succinate, this dose is 200 mg daily.
Please be advised that beta blockers, due to varying properties, are not fully equivalent. In
general, when switching to a beta blocker with CHF benefit, consider a dose that is an
equivalent percentage (or less) of the maximum dose of the beta blockers being selected for
conversion. Some patients may require doses different from the ones provided in this table as
being more or less equivalent.
References found within the UW Health Heart Failure – Adult – Inpatient/Ambulatory Clinical Practice Guideline.
Last reviewed/revised: 12/2015
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2015CCKM@uwhealth.org

19
References
1. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management
of heart failure: a report of the American College of Cardiology Foundation/American
Heart Association Task Force on practice guidelines. Circulation. Oct
2013;128(16):e240-327.
2. Swedberg K, Komajda M, Böhm M, et al. Ivabradine and outcomes in chronic heart
failure (SHIFT): a randomised placebo-controlled study. Lancet. Sep
2010;376(9744):875-885.
3. McMurray JJ, Packer M, Desai AS, et al. Angiotensin-neprilysin inhibition versus
enalapril in heart failure. N Engl J Med. Sep 2014;371(11):993-1004.
4. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management
of heart failure: executive summary: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on practice guidelines. Circulation.
Oct 2013;128(16):1810-1852.
5. Mirski MA, Frank SM, Kor DJ, Vincent JL, Holmes DR. Restrictive and liberal red cell
transfusion strategies in adult patients: reconciling clinical data with best practice. Crit
Care. 2015;19:202.
6. McQuilten ZK, Crighton G, Engelbrecht S, et al. Transfusion interventions in critical
bleeding requiring massive transfusion: a systematic review. Transfus Med Rev. Apr
2015;29(2):127-137.
7. Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for
septic shock. N Engl J Med. Apr 2015;372(14):1301-1311.
8. Nahirniak S, Slichter SJ, Tanael S, et al. Guidance on platelet transfusion for patients
with hypoproliferative thrombocytopenia. Transfus Med Rev. Jan 2015;29(1):3-13.
9. Kaufman RM, Djulbegovic B, Gernsheimer T, et al. Platelet transfusion: a clinical
practice guideline from the AABB. Ann Intern Med. Feb 2015;162(3):205-213.
10. Goodnough LT, Maggio P, Hadhazy E, et al. Restrictive blood transfusion practices are
associated with improved patient outcomes. Transfusion. Oct 2014;54(10 Pt 2):2753-
2759.
11. Goodnough LT, Levy JH, Murphy MF. Concepts of blood transfusion in adults. Lancet.
May 2013;381(9880):1845-1854.
12. Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical
practice guideline from the AABB*. Ann Intern Med. Jul 2012;157(1):49-58.
13. Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 Guideline Update for the
Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the
American College of Cardiology/American Heart Association Task Force on Practice
Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and
Management of Heart Failure): developed in collaboration with the American College of
Chest Physicians and the International Society for Heart and Lung Transplantation:
endorsed by the Heart Rhythm Society. Circulation. Sep 20 2005;112(12):e154-235.
14. Jessup M, Abraham WT, Casey DE, et al. 2009 focused update: ACCF/AHA 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: developed in collaboration with the International Society for Heart and Lung
Transplantation. Circulation. Apr 14 2009;119(14):1977-2016.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2015CCKM@uwhealth.org