PHARMASTE · POCKET GUIDE
Heart failure
Focused adult pharmacy study guide for chronic HF treatment, medication monitoring, congestion, transitions and selected calculations. It is not a complete acute-care, pregnancy, cardiomyopathy or device-prescribing protocol. Use patient-specific assessments and current product instructions for clinical care.
1. Read the case before choosing the drug
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| Treatment-guideline category | EF context | Practical implication |
|---|---|---|
| HFrEF | LVEF ≤40% | Assess eligibility for four foundational classes. |
| HFmrEF | LVEF 41–49% | SGLT2 treatment and individualized phenotype-directed therapy; avoid assuming every HFrEF recommendation has identical evidence. |
| HFpEF | LVEF ≥50% | Treat congestion, comorbidities and the underlying phenotype. |
| Improved EF | Prior LVEF ≤40%, now >40% in the 2022 guideline | Continue tolerated HFrEF GDMT to reduce relapse risk; improvement does not automatically justify withdrawal. |
- Identify the cause of HF, current symptoms, congestion and perfusion, EF trajectory, kidney function, potassium, BP, HR/rhythm, comorbidities and the complete medication list.
- This table uses 2022 U.S. treatment-guideline categories to interpret the evidence underlying many prescriptions. The 2026 universal definition moves toward reduced, preserved and improved EF categories without rigid universal cutoffs; it does not replace drug-label thresholds or treatment guidelines.
- HFpEF requires a compatible clinical syndrome and supporting assessment. Preserved EF alone does not establish HF; obesity may lower natriuretic peptides. Consider mimics and integrate imaging, laboratory findings and indicated additional testing.
Pause & recall
Why does an EF of 58% neither confirm nor exclude clinical HF by itself?
Sources: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure — official slide set · 2026 Second Universal Definition of Heart Failure · 2026 ACC Expert Consensus Decision Pathway: HFpEF — official key takeaways
2. Build the HFrEF foundation
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| Class | Examples and dose anchors | Safety checkpoint |
|---|---|---|
| ARNI; ACEi/ARB when ARNI is not feasible | Sacubitril/valsartan: start 49/51 mg twice daily; use 24/26 mg twice daily when ACEi/ARB-naive or previously on low doses, eGFR <30 mL/min/1.73 m², or moderate hepatic impairment. Titrate every 2–4 weeks toward 97/103 mg twice daily as tolerated. | 36-hour ACEi washout; no concurrent ACEi or additional ARB. Prior ACEi/ARB angioedema is a contraindication. Monitor BP, K and kidney function; pregnancy requires prompt discontinuation and coordinated review. |
| Evidence-based beta-blocker | Start → target as tolerated: carvedilol 3.125 mg twice daily → 25–50 mg twice daily (higher target in selected patients >85 kg); metoprolol succinate extended-release 12.5–25 mg daily → 200 mg daily; bisoprolol 1.25 mg daily → 10 mg daily. Give carvedilol with food; titrate no faster than every 2 weeks. | Start after compensation; defer carvedilol during IV inotropic support. Watch HR, BP and fluid retention. Do not abruptly stop without a clinical plan. |
| Steroidal MRA | Guideline start → target as tolerated: spironolactone 12.5–25 mg daily → 25–50 mg daily; eplerenone 25 mg daily → 50 mg daily. Adjust for kidney function, K and interactions; the spironolactone label suggests 25 mg every other day when eGFR is 30–50 mL/min/1.73 m². | For HFrEF initiation: eGFR >30 mL/min/1.73 m² and K <5.0 mEq/L. For spironolactone, check K within 1 week of initiation/titration; monitor regularly thereafter. Review supplements and salt substitutes. |
| SGLT2 inhibitor | Dapagliflozin 10 mg daily or empagliflozin 10 mg daily for HF; diabetes is not required. | Check product-specific renal criteria and volume status. Dapagliflozin initiation for HF is not recommended below eGFR 25 mL/min/1.73 m². Hold for at least 3 days before surgery/prolonged fasting when possible; resume when stable and eating. |
- For eligible, compensated patients, introduce all four classes promptly and titrate toward tolerated targets with planned reassessment. Do not wait for one medicine to reach its maximum before introducing every other class.
- A loop diuretic treats congestion but is not one of the four foundational disease-modifying classes. Financial access, adherence and a workable monitoring plan affect whether the regimen succeeds.
Pause & recall
Name the four classes. Which medicine addresses excess fluid without substituting for those classes?
Sources: 2024 ACC Expert Consensus Decision Pathway for Treatment of HFrEF — ACC key points · ENTRESTO U.S. prescribing information · Carvedilol immediate-release tablets U.S. prescribing information, Teva source label · ALDACTONE U.S. prescribing information · FARXIGA U.S. prescribing information · 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure — official slide set
3. Match the diuretic plan to the examination
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| Finding | Interpretation | Next assessment |
|---|---|---|
| Persistent edema, orthopnea and inadequate urine output | Congestion may require loop-dose intensification. | Review response, adherence, perfusion, BP, weight, renal function and electrolytes. A small isolated creatinine rise does not automatically mean all decongestion must stop. |
| Inadequate response despite moderate/high loop doses | A thiazide-type add-on such as metolazone may be considered. | Reserve combination therapy for inadequate loop response; monitor sodium, K, magnesium, renal function, BP and volume status closely. |
| Orthostasis, low BP and examination consistent with volume depletion | The current diuretic requirement may be lower. | Promptly reassess; reduce or interrupt excess diuresis as appropriate while seeking reversible causes and preserving tolerated GDMT. |
| New vomiting, abdominal pain or unexplained dyspnea during SGLT2 treatment | Ketoacidosis can occur without marked hyperglycemia. | Interrupt the medicine and seek urgent assessment; do not use a near-normal glucose to dismiss the symptoms. |
- Daily weight and symptom trends are most useful when linked to an individualized action plan. Severe breathlessness at rest, syncope, chest pain or new confusion calls for emergency assessment.
Pause & recall
What findings distinguish excessive diuresis from persistent congestion in a patient whose creatinine increased?
Sources: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure — official slide set · Bumetanide tablets U.S. labeling · ALDACTONE U.S. prescribing information · FARXIGA U.S. prescribing information
4. HFpEF, HFmrEF and finerenone
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| Finerenone HF step | Label anchor | Follow-up |
|---|---|---|
| Before initiation | Measure K and eGFR. Do not start if K >5.0 mEq/L; initiation is not recommended if eGFR <25 mL/min/1.73 m². | Screen for strong CYP3A4 inhibitors and adrenal insufficiency, both contraindications. |
| Initiation eGFR ≥60 mL/min/1.73 m² | Start 20 mg daily; potential HF target 40 mg daily. | At 4 weeks use current K, eGFR change and the HF dose table to decide whether to increase. |
| Initiation eGFR 25 to <60 mL/min/1.73 m² | Start 10 mg daily; potential HF target 20 mg daily. | Recheck K/eGFR 4 weeks after starting or adjusting, then periodically. A >30% eGFR decline prevents upward titration in the table. |
- The 2026 ACC HFpEF pathway emphasizes early SGLT2 therapy, consideration of a nonsteroidal MRA when appropriate, control of congestion and management of obesity, hypertension, atrial fibrillation, kidney disease and other comorbidities.
- Use beta-blockers for a specific indication rather than automatically for every HFpEF patient. Phenotype-directed options may include incretin-based obesity therapy or selected ARNI/ARB use; check eligibility and the intended outcome.
- Finerenone is labeled for adults with HF and LVEF ≥40%, without a diabetes requirement. It is not an automatic replacement for spironolactone/eplerenone in an HFrEF foundational regimen, and combining MRAs is not routine.
Pause & recall
Why can one eligible HF patient have a finerenone target of 40 mg while another has a target of 20 mg?
Sources: 2026 ACC Expert Consensus Decision Pathway: HFpEF — official key takeaways · KERENDIA U.S. prescribing information · FARXIGA U.S. prescribing information
5. Selected additions after the foundation
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| Option | When to recognize it | What not to miss |
|---|---|---|
| Hydralazine + isosorbide dinitrate | Guideline-supported add-on for self-identified African American patients with persistent NYHA III–IV HFrEF on optimal therapy; may also be considered when first-line renin–angiotensin therapy cannot be used. | Nitrates and sildenafil/PDE5 inhibitors are contraindicated together; simple dose separation is not a safe routine workaround. |
| Ivabradine | Selected stable symptomatic HFrEF: LVEF ≤35%, sinus rhythm, resting HR ≥70 beats/min despite maximally tolerated beta-blocker therapy. | It is not a substitute for completing appropriate foundational treatment; check rhythm and bradycardia risk. |
| Digoxin | Selected persistent symptoms despite GDMT; may also serve a rate-control role in atrial fibrillation. | For HF, target serum concentration 0.5 to <0.9 ng/mL. Sample before the next dose or ≥6 hours after dosing. Interpret with symptoms, renal function, electrolytes and interactions such as amiodarone. |
| IV ferric carboxymaltose | Labeled to improve exercise capacity in adults with HF, NYHA II/III and iron deficiency. Assess ferritin and TSAT, not hemoglobin alone. | August 2026 boxed warning: serious prolonged hypophosphatemia. Correct pre-existing hypophosphatemia; check phosphate before repeat courses in at-risk patients and anyone repeating within 3 months. Observe for hypersensitivity during and ≥30 minutes after treatment until stable. |
| Vericiguat | Selected symptomatic chronic HF with EF <45% after HF hospitalization or outpatient IV diuretic need. | January 2026 label: start 5 mg daily with food, or 2.5 mg if at risk of symptomatic hypotension; titrate about every 2 weeks toward 10 mg as tolerated. Contraindicated in pregnancy and with other soluble guanylate cyclase stimulators; PDE5 co-use is not recommended. |
Pause & recall
Which add-on has a newly prominent phosphate warning, and which one has a 2026 change in its usual starting dose?
Sources: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure — official slide set · Digoxin oral solution U.S. prescribing information · INJECTAFER U.S. prescribing information · VERQUVO U.S. prescribing information · Sildenafil tablets U.S. prescribing information
6. Make the plan usable at home
- Reconcile the final medication list, including the exact beta-blocker formulation, discontinued ACEi/ARB prescriptions, duplicate doses, potassium products and NSAIDs. Explain the purpose of each drug.
- Confirm affordability, supply and a practical schedule. Ask the patient to teach back the doses, monitoring and individualized weight/symptom thresholds for calling the team.
- After hospitalization, arrange early follow-up, generally within 7 days. Record when laboratory tests are due, who will interpret them and how the patient will receive instructions.
- Use a consistent daily weighing routine, a personalized sodium/fluid plan and appropriate exercise or rehabilitation. Avoid issuing the same strict fluid limit to every patient regardless of clinical status.
- Discuss pregnancy planning and drug-specific precautions before exposure. A newly confirmed pregnancy while taking an ARNI/ACEi/ARB requires prompt coordinated review.
- Repeated admissions, progressive symptoms or inability to tolerate therapy warrant timely HF-specialist assessment. Persistent LVEF ≤35% despite chronic GDMT may prompt ICD evaluation when other criteria are met; CRT additionally depends on ECG/conduction and clinical criteria.
Pause & recall
Can the patient explain what changed, what to watch for and which clinician will review the next potassium result?
Sources: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure — official slide set · 2024 ACC Expert Consensus Decision Pathway for Treatment of HFrEF — ACC key points · ENTRESTO U.S. prescribing information · ALDACTONE U.S. prescribing information · FARXIGA U.S. prescribing information
7. Three calculation habits
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| Task | Set up the units | Check before using the result |
|---|---|---|
| Oral loop conversion | Using the supplied approximation: oral furosemide 40 mg ≈ oral bumetanide 1 mg. Furosemide 80 mg twice daily gives 160 mg/day → about 4 mg/day bumetanide. | State route, approximation and total daily dose; choose the schedule and subsequent dose from clinical response. |
| Infusion pump rate | 500 mg in final 250 mL = 2 mg/mL. A 10-mg/hour order requires 10 ÷ 2 = 5 mL/hour. | Use final bag volume, confirm mg/hour versus mL/hour, and independently verify the order. |
| Oral solution volume | 0.125 mg = 125 mcg. With 50 mcg/mL: 125 ÷ 50 = 2.5 mL per dose. | Confirm formulation and concentration; use a calibrated oral syringe rather than a household spoon. |
Pause & recall
What error occurs if you convert a twice-daily loop dose but forget to calculate the total daily amount?
Sources: Bumetanide tablets U.S. labeling · Digoxin oral solution U.S. prescribing information · NABP NAPLEX Content Outline
Abbreviations
- HF
- heart failure
- HFrEF
- HF with reduced ejection fraction
- HFmrEF
- HF with mildly reduced ejection fraction in the 2022 treatment guideline
- HFpEF
- HF with preserved ejection fraction
- HFimpEF
- HF with improved ejection fraction
- LVEF
- left ventricular ejection fraction
- GDMT
- guideline-directed medical therapy
- NYHA
- New York Heart Association functional class
- ARNI
- angiotensin receptor–neprilysin inhibitor
- ACEi
- angiotensin-converting enzyme inhibitor
- ARB
- angiotensin II receptor blocker
- MRA
- mineralocorticoid receptor antagonist
- SGLT2
- sodium–glucose cotransporter 2
- eGFR
- estimated glomerular filtration rate
- BP
- blood pressure
- HR
- heart rate
- K
- potassium
- NSAID
- nonsteroidal anti-inflammatory drug
- IV
- intravenous
- ECG
- electrocardiogram
- ICD
- implantable cardioverter-defibrillator
- CRT
- cardiac resynchronization therapy
- MI
- myocardial infarction
- PDE5
- phosphodiesterase type 5
- TSAT
- transferrin saturation
- mEq
- milliequivalent
- mcg
- microgram
Sources & verification
Guide reviewed . Source checks are dated below. These selected teaching points use the guidance and product references below. Confirm current labeling, the patient's circumstances, and local protocols before applying a regimen.
- 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure — official slide set — Diuretics, HFrEF pharmacotherapy, HFmrEF, improved EF, ICDs and transitions of care; slides 68–113 and 154–156 · Checked https://professional.heart.org/en/science-news/-/media/832EA0F4E73948848612F228F7FA2D35.ashx
- 2026 Second Universal Definition of Heart Failure — Classification of HF According to LVEF; Trajectories; relationship to treatment guidelines · Checked https://reference-global.com/article/10.5334/gh.1569?tab=article
- 2026 ACC Expert Consensus Decision Pathway: HFpEF — official key takeaways — Structured diagnosis, foundational and phenotype-directed therapy, congestion, comorbidities and longitudinal care · Checked https://www.acc.org/-/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Tools-and-Practice-Support/Clinical-Solutions/2026/B26070-HFpEF-Management-ECDP-Key-Takeaways.pdf
- 2024 ACC Expert Consensus Decision Pathway for Treatment of HFrEF — ACC key points — Points 1–3: early foundational treatment, compensation before beta-blocker initiation and specialist referral · Checked https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2024/03/06/19/22/2024-acc-expert-consensus-hfref
- ENTRESTO U.S. prescribing information — Boxed warning; 2.1–2.2, 2.6–2.8, 4, 5.1–5.5 and 7.1 · Checked https://www.novartis.com/us-en/sites/novartis_us/files/entresto.pdf
- Carvedilol immediate-release tablets U.S. prescribing information, Teva source label — 2.1, 4 and 5.1–5.4: compensated HF, dose titration, food and safety · Checked https://www.dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=da2696ba-f4be-4626-9abe-fe33f36361b1&type=display
- ALDACTONE U.S. prescribing information — 2.2, 5.1–5.3 and 7.1: HF dosing, potassium, renal/volume monitoring and interactions · Checked https://labeling.pfizer.com/ShowLabeling.aspx?id=520
- FARXIGA U.S. prescribing information — 1, 2.1–2.4, 5.1–5.3: HF dose, renal eligibility, fasting, ketoacidosis and volume depletion · Checked https://www.dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=72ad22ae-efe6-4cd6-a302-98aaee423d69
- Bumetanide tablets U.S. labeling — Clinical Pharmacology; Warnings and Precautions: approximate potency, fluid and electrolyte depletion · Checked https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=b338ae20-fc07-4ec5-9e68-be636f75ce1a&type=display
- KERENDIA U.S. prescribing information — 1, 2.1–2.3 Table 3, 4 and 5.1–5.2: HF with LVEF ≥40%, renal-function-dependent target and potassium safety · Checked https://labeling.bayerhealthcare.com/html/products/pi/Kerendia_PI.pdf
- Digoxin oral solution U.S. prescribing information — 2.2, 3, 5 and 7: serum sampling, 50 mcg/mL solution, toxicity and interactions · Checked https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=1b7e5c6e-e052-41b0-a4ce-05dfe62faaaf
- INJECTAFER U.S. prescribing information — Boxed warning; 1, 2.1–2.3 and 5.1–5.3: HF indication, phosphate and infusion safety · Checked https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=517b4a19-45b3-4286-9f6a-ced4e10447de
- VERQUVO U.S. prescribing information — 1, 2.1–2.2, 4 and 7: selected HF use, updated starting dose, pregnancy and interactions · Checked https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=17056d73-1b1b-4bf2-9c07-b7a9367f0d6d
- Sildenafil tablets U.S. prescribing information — 4.1 and 7.1: nitrate contraindication · Checked https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=6d8dbaa6-d61a-46ae-a641-f664104f4714&type=display
- NABP NAPLEX Content Outline — Detailed outline pages 4–5; Pharmaste editorial mapping, not endorsement · Checked https://nabp.pharmacy/wp-content/uploads/NAPLEX-Content-Outline.pdf
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