Flow diagram of the recommended pharmacological management of heart failure adapted from the European Society of Cardiology guidelines 2016. Flow diagram.

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Flow diagram of the recommended pharmacological management of heart failure adapted from the European Society of Cardiology guidelines 2016. Flow diagram of the recommended pharmacological management of heart failure adapted from the European Society of Cardiology guidelines 2016. The term symptomatic refers to New York Heart Association class II–IV, if asymptomatic consider reducing furosemide dose. CRT, ivabradine and ARNIs should be used in combination when appropriate. If despite the above persistent symptoms remain, digoxin, hydralazine and isosorbide dinitrate, left ventricular assist devices and heart transplantation can be considered by a specialist. HFrEF, heart failure with reduced ejection fraction; ACE-i, angiotensin-converting enzyme inhibitor; BB, β-blocker; MRA, mineralocorticoid receptor antagonist; ARNI, angiotensin receptor neprilysin inhibitor; CRT, cardiac resynchronisation therapy; ICD, implantable cardiac defibrillator; VT, ventricular tachycardia; VF, ventricular fibrillation; OMT, optimal medical therapy. aUse angiotensin receptor blocker (ARB) instead of ACE-i when intolerant/contraindicated. bUse ARB instead of MRA when intolerant/contraindicated. cAt doses equivalent to enalapril 10 mg twice daily. dOnly if B-type natriuretic peptides (BNP) ≥150 pg/mL or plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) ≥600 pg/mL, unless there has been a heart failure-related admission in the previous 12 months, when the cut-offs are BNP ≥100 pg/mL or NT-proBNP ≥400 pg/mL.35 Christopher Orsborne et al. Postgrad Med J 2017;93:29-37 Copyright © The Fellowship of Postgraduate Medicine. All rights reserved.