Pharmacologic Algorithm for Congestive Heart Failure

(revised 2004; page 1)

Treat HTN,
CAD if
present

Patients with HF symptoms:

Dyspnea, Fatigue, Exercise
Intolerance

Follow regularly to
Assess response to
Treatment Q4-6 months

No

Systolic
Dysfunction

Perform Echo, CXR, ECG

Physical Exam
Assess volume Status
Determine Functional Class

Yes
2,4

*Start ACE-I; Achieve Target Dose

3
*Diuretic if Volume Overloaded
*Discontinue Type I antiarrhythmics, calcium
antagonists, NSAIDs
*Anticoagulate
Mobile Thrombus
Prior Thromboembolism
Atrial Fibrillation (Afib)
*If Afib consider cardioversion, Amiodarone
*Vtach/SCD: EPS Consult

R/O CAD
Assess Myocardial Viability
*Thallium Stress
*Stress Echo
R/O Valvular disease
*Cardiac Catheterization

Refer for:
Revascularization
Or
Valve
Repair/Replacement
Reduce CAD Risks

Significant
CAD
Or Valve
Disease?

Yes

ACE-I
Intolerant?

No
Consult:
CT Surgery or
Interventional
Cardiology

Yes

Hydralazine + ISDN

No

Search for other causes

Nonischemic, nonvalvular CM:
ETOH, drugs, HTN, low
thyroid, etc.

Symptoms
Resolve
?

Yes

Follow regularly to
assess response to
treatment Q-6 months

No
1

*Add Carvedilol
*Re-evaluate volume status and diuretic needs
No

Symptoms
Resolve
?

Yes

Follow regularly to
assess response to
treatment Q4-6 months

No
*Consider Amlodipine, Felodipine
Hydralazine/ISDN
*Re-evaluate volume status and
diuretic needs.

Follow regularly to
assess response to
treatment q 4-6 months

Yes

Yes

Is patient
Hypertensive
?
No

Symptoms
Resolve?

No

*Re-evaluate volume status

and diuretic needs.
*Add Digoxin

1. Consider Cardiology Consult, See Beta

Blocker position statement
2. Target Doses:
Captopril 50-100 mg TID
Enalapril 10 mg BID
Trandolapril 4 mg qd
Fosinopril 40 mg qd
3. See Diuretic Algorithm
4. See ACE-inhibitor Position Statement
5. See ACE-inhibitor Intolerance Position
Statement