16, 2013 2013 ACCF/AHA Heart Failure Guidelines: Executive Summary October 15, 2013:1495 539 Table 14. Recommendations for Pharmacological Therapy for Management of Stage C HFrEF Recommendations COR LOE References Diuretics Diuretics are recommended in patients with HFrEF with fluid retention I C N/A ACE inhibitors ACE inhibitors are recommended for all patients with HFrEF I A 134,167 169 ARBs ARBs are recommended in patients with HFrEF who are ACE inhibitor intolerant I A 136,170,171,189 ARBs are reasonable as alternatives to ACE inhibitors as first-line therapy in HFrEF IIa A 190 195 Addition of an ARB may be considered in persistently symptomatic patients with HFrEF on GDMT IIb A 176,196 Routine combined use of an ACE inhibitor, ARB, and aldosterone antagonist is potentially harmful III: Harm C N/A Beta blockers Use of 1 of the 3 beta blockers proven to reduce mortality is recommended for all stable patients I A 137,172 175,187 Aldosterone receptor antagonists Aldosterone receptor antagonists are recommended in patients with NYHA class II IV who have LVEF 35% I A 181,182,197 Aldosterone receptor antagonists are recommended in patients following an acute MI who have LVEF 40% with symptoms of HF or DM I B 184 Inappropriate use of aldosterone receptor antagonists may be harmful III: Harm B 198,199 Hydralazine and isosorbide dinitrate The combination of hydralazine and isosorbide dinitrate is recommended for African Americans with NYHA class III IV HFrEF on GDMT I A 179,180 A combination of hydralazine and isosorbide dinitrate can be useful in patients with HFrEF who cannot be given ACE inhibitors or ARBs IIa B 188 Digoxin Digoxin can be beneficial in patients with HFrEF IIa B 202 209 Anticoagulation Patients with chronic HF with permanent/persistent/paroxysmal AF and an additional risk factor for cardioembolic stroke should receive chronic anticoagulant therapy* I A 210 216 The selection of an anticoagulant agent should be individualized I C N/A Chronic anticoagulation is reasonable for patients with chronic HF who have permanent/ persistent/paroxysmal AF but are without an additional risk factor for cardioembolic stroke* IIa B 211 213,217 219 Anticoagulation is not recommended in patients with chronic HFrEF without AF, a prior thromboembolic event, or a cardioembolic source III: No Benefit B 220 222 Statins Statins are not beneficial as adjunctive therapy when prescribed solely for HF III: No Benefit A 223 228 Omega-3 fatty acids Omega-3 PUFA supplementation is reasonable to use as adjunctive therapy in HFrEF or HFpEF patients IIa B 229,230 Other drugs Nutritional supplements as treatment for HF are not recommended in HFrEF III: No Benefit B 231,232 Hormonal therapies other than to correct deficiencies are not recommended in HFrEF III: No Benefit C N/A Drugs known to adversely affect the clinical status of patients with HFrEF are potentially harmful and should be avoided or withdrawn III: Harm B 233 244 Long-term use of an infusion of a positive inotropic drug is not recommended and may be harmful except as palliation III: Harm C N/A Calcium channel blockers Calcium channel blocking drugs are not recommended as routine treatment in HFrEF III: No Benefit A 238,245,246 *In the absence of contraindications to anticoagulation. 