Tina revisits ACEI, ARB, BB, and Thiazides, which were covered previously with the hypertension episodes, and introduces a few new medications as well:

• 
  
• Mineralocorticoid Receptor Antagonists: spironolactone and eplerenone
  
• Loop diuretic: furosemide
  
• Digoxin
  
• Vasodilators: hydralazine and isosorbite dinitrate
  

For a quick summary of the CCS 2013 recommendations:

ACE inhibitors:

• 
  
• all asymptomatic patients with an EF < 35%
  
• all symptomatic HF patients and EF < 40%
  

ARB:

• 
  
• if intolerant to ACEI
  
• add to ACEI if intolerant or contraindicated for BB
  
• add to ACEI and BB if NYHA class II-IV HF and EF ≤ 40% deemed at increased risk of HF events
  

BB:

• 
  
• all HF patients with an EF ≤ 40%
  
• initiated at a low dose and titrated to the target dose or maximal tolerated dose
  

MRA:

• 
  
• patients > 55 years with mild to moderate HF during standard HF treatments with EF ≤ 30% (or ≤ 35% if QRS duration > 130 ms) and recent (6 months) hospitalization for CV disease or
  
• with elevated BNP or NT-proBNP levels
  
• after an MI with EF ≤ 30% and HF or
  
• EF ≤ 30% alone in the presence of diabetes
  
• EF < 30% and severe chronic HF (NYHA IIIB-IV) despite optimization of other recommended treatments
  

Diuretics:

• 
  
• for congestive symptoms
  
• When acute congestion is cleared, the lowest dose should be used that is compatible with stable signs and symptoms
  
• persistent volume overload despite optimal medical therapy and increases in loop diuretics, cautious addition of a second diuretic (a thiazide or low dose metolazone) may be considered as long as it is possible to closely monitor morning weight, renal function, and serum potassium
  

Digoxin:

• 
  
• patients in sinus rhythm who continue to have moderate to severe symptoms, despite optimized HF therapy
  
• patients with chronic atrial fibrillation (AF) and poor control of ventricular rate
  

Isosorbide dinitrate and hydralazine:

• 
  
• black Canadians with HF-REF
  
• non-black HF patients unable to tolerate an ACE inhibitor or ARB
  

Drug information from:

• 
  
• Drug monographs
  
• CPS: http://www.e-therapeutics.ca/
  
• Therapeutic Choices: http://www.e-therapeutics.ca/
  
• Rx Files: http://www.rxfiles.ca/rxfiles/modules/druginfoindex/druginfo.aspx
  

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