Table 1.

Heart failure drugs overview comparison chart

CLASSDRUG (BRAND NAME)INITIAL ORAL DOSE (TARGET DOSE)COST/MO FOR TARGET DOSE, $USE AND COMMENTS
ACEIsRamipril (Altace)1.25–2.5 mg twice daily (5 mg twice daily or 10 mg once daily)43 or 29
  • use in all patients as soon as safely possible after AMI and continue indefinitely in LVEF < 40% or if AHF complicated the AMI

  • use in all asymptomatic patients with LVEF < 35% and all patients with symptoms of HF and LVEF < 40%

  • good evidence for decreased mortality in HF; can use in combination with diuretic (if decreased weight or drop in BP occurs, hold or decrease diuretic dose and maintain ACEI dose) (ACEI vs placebo for trials up to 42 months’ duration: all-cause mortality 15.8% vs 21.9%, NNT = 16; all-cause mortality or HF hospitalization 22.4% vs 32.6%, NNT = 10)

  • monitor: serum creatinine and potassium upon initiation and within 3–7 days of starting or adjusting dose (up to a 30% increase in serum creatinine and a potassium level up to 5.6 mmol/L might be reasonable)

Lisinopril (Zestril)2.5–5 mg daily (20–40 mg daily)28–58
Perindopril (Coversyl)2 mg daily (4 mg daily)35
Enalapril (Vasotec)1.25–2.5 mg twice daily (10 mg twice daily)42
Captopril (Capoten)6.25–12.5 mg 3 times daily (25–50 mg 3 times daily)37–62
Trandolapril (Mavik)0.5–1 mg daily (4 mg daily)42
BBs (Agents only listed if evidence of decreased mortality in HF; might not be a class effect)Bisoprolol (Monocor)1.25 mg daily (10 mg daily)21
  • use in all HF patients with LVEF ≤ 40%; if NYHA class IV symptoms, stabilize patient and congestion before initiation of a BB (eg, not for AHF)

  • BBs improve ventricular function, patient well-being, and survival; decrease hospitalizations; and treat atrial fibrillation

  • avoid abrupt withdrawal; if necessary, can titrate the dose down (by half) in AHF and titrate up once stabilized

  • bisoprolol and carvedilol have mortality benefit10,11 (eg, bisoprolol vs placebo: all-cause mortality 11.8% vs 17.3%, NNT=19/1.3 years); for metoprolol, evidence stronger with tartrate salt (long-acting formulation) used in the United States3,12

Carvedilol (Coreg)3.125–6.25 mg twice daily (25 mg twice daily with food)53
Metoprolol SR (Lopressor [succinate salt in Canada])12.5–25 mg daily (200 mg SR daily)21
ARB (Only valsartan and candesartan have official HF indications)Candesartan (Atacand)4 mg daily (32 mg daily)48
  • use when ACEI not tolerated (eg, due to cough)

  • ARBs at high doses have shown similar outcome benefits to ACEIs13,14

  • ARBs and ACEIs sometimes, although not routinely, combined; adverse events with little extra benefit15,16

  • monitor: similar to ACEI (see above)

Valsartan (Diovan)40 mg twice daily (160 mg twice daily)92
Losartan (Cozaar)25–50 mg daily (≤ 150 mg daily)74
Aldosterone antagonistsSpironolactone (Aldactone)12.5 mg daily (12.5–25 mg daily; maximum 50 mg daily)9
  • option for patients with LVEF < 30% and severe HF symptoms despite treatment optimization, or with AHF with LVEF < 30%

  • consider lowering or discontinue potassium supplements when starting; counsel regarding potassium; hold if diarrhea or vomiting

VasodilatorsIsosorbide dinitrate (Isordil)20 mg 3 times a day before meals (40 mg 3 times a day before meals)23
  • combination ISDN and hydralazine useful in African Americans with systolic dysfunction (decrease mortality), patients unable to tolerate standard treatment, and chronic renal failure

  • ISDN or nitroglycerin patch also useful for nocturnal dyspnea; maintain a 12-hour nitro-free interval

Hydralazine (Apresoline)37.5 mg 3 times a day (75 mg 3 times a day)48
DiureticsFurosemide20–40 mg daily to twice daily5
  • furosemide useful for congestive symptom relief; once congestion resolves, reduce to lowest effective dose or stop so that agents with mortality evidence can be optimized; a second diuretic (thiazide or metolazone) might be useful to augment loop diuretic when necessary

Hydrochlorothiazide12.5–25 mg daily to twice daily5
Metolazone (Zaroxolyn)2.5–5 mg daily10–17
Cardiac glycosideDigoxin0.0625–0.125 mg daily for most (target low blood levels ≤ 1.3 nmol/L in HF, as higher levels are associated with harm)15
  • evidence for symptomatic and hospitalization benefit, but not mortality

  • might be useful for patients with both HF and atrial fibrillation when not controlled on BBs

  • many contraindications, drug interactions, and side effects

  • ACEI—angiotensin-converting enzyme inhibitor, AHF—acute heart failure, AMI—acute myocardial infarction, ARB—angiotensin receptor blocker, BB—β-blocker, BP—blood pressure, HF—heart failure, ISDN—isosorbide dinitrate, LVEF—left ventricle ejection fraction, NNT—number needed to treat, NYHA—New York Heart Association, SR—sustained release.

  • Data from Jin et al.2

  • Full version of the RxFiles heart failure overview and treatment chart is available on CFPlus.*