3. Restricción de sodio
● Recomendación de 2 gr - 3 gr de Na al dia
○ Nivel de evidencia II-C
■ No hay evidencia clara en qué grupos se benefician más y
en algunos caso aumenta eventos adversos. Todavía está
en estudio verdadero beneficio#
# - Colin-Ramirez E, McAlister FA, Zheng Y, et al. Changes in dietary intake and nutritional status associated with a significant reduction in sodium intake in patients with
heart failure. A sub-analysis of the SODIUM-HF pilot study. Clin Nutr ESPEN. 2016;11:e26–e32.
Hummel SL, Karmally W, Gillespie BW, et al. Home-delivered meals postdischarge from heart failure hospitalization. Circ Heart Fail. 11;2018:e004886.
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on
Clinical Practice Guidelines
4. Vacunacion
● Influenza (Anual)* Nivel de evidencia 2a-B
● COVID 19 bivalente (Anual) Nivel de evidencia 2a-B
● Pneumococco Nivel de evidencia 2a-B
○ Vacuna conjugada 13 valente y vacuna polisacárida 23 valente 2
meses después)
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint
Committee on Clinical Practice Guidelines
*Angiotensin–Neprilysin Inhibition versus Enalapril in Heart Failure, John J.V. McMurray, Milton Packer, Akshay S. Desai, et al, The New England Journal of
Medicine, Massachusetts Medical Society, Sep 11, 2014
5. Actividad física
● Actividad física con un mínimo de 40 min unas 5 veces a la
semana*
○ Recomendacion 1-A
● Rehabilitación cardiovascular con equipo multidisciplinario
○ Recomendacion 2a-B
* O'Connor CM, Whellan DJ, Lee KL, Keteyian SJ, Cooper LS, Ellis SJ, Leifer ES, Kraus WE, Kitzman DW, Blumenthal JA, Rendall DS, Miller NH, Fleg JL, Schulman KA, McKelvie
RS, Zannad F, Piña IL; HF-ACTION Investigators. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA.
2009 Apr 8;301(14):1439-50. doi: 10.1001/jama.2009.454. PMID: 19351941; PMCID: PMC2916661.
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on
Clinical Practice Guidelines
7. Inhibición del sistema renina-angiotensina
● Opciones: ARNi > IECA > ARA2
● Sacubitril + Valsartan
○ Dosis inicio 49+51 mg cada 12 hs y dosis objetivo 97+103 mg cada 12 hs
■ Mayor reducción en mortalidad y morbilidad (20% en comparación con
IECA)*
■ Recomendacion 1-A
○ Si IECA previo suspender 36 hs antes del inicio de ARNi para evitar angioedema
○ Contraindicados en pacientes con historia de angioedema (3 daño C-LD)
○ Mayor efecto hipotensor
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical
Practice Guidelines
2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, ESC Clinical Practice Guidelines, 25 Aug 2021
*Angiotensin–Neprilysin Inhibition versus Enalapril in Heart Failure, John J.V. McMurray, Milton Packer, Akshay S. Desai, et al, The New England Journal of Medicine,
Massachusetts Medical Society, Sep 11, 2014
9. Inhibición del sistema renina-angiotensina
● IECAs recomendados sobre ARA2
○ Recomendados cuando no se toleran ARNi (nivel 1-A)
○ Mayor incidencia de angioedema
○ Mayor incidencia de tos > niveles de bradiquinina por
inhibición de su degradación
○ Contraindicados en historia de angioedema (3 daño C-LD)
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee
on Clinical Practice Guidelines
2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, ESC Clinical Practice Guidelines, 25 Aug 2021
10. Inhibición del sistema renina-angiotensina
● Enalapril
○ Dosis de inicio de 2.5 mg cada 12 hs y dosis objetivo de 10 mg a
20 mg cada 12 hs
● Captopril
○ Dosis de inicio de 6.25 mg cada 8 hs y dosis objetivo de 50 mg
cada 8 hs
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee
on Clinical Practice Guidelines
2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, ESC Clinical Practice Guidelines, 25 Aug 2021
11.
12. Inhibición del sistema renina-angiotensina
● ARA2 recomendados ante la intolerancia de ARNi e IECA
● Losartan
○ Dosis de inicio 50 mg cada 24 hs y dosis objetivo 150 mg cada 24 hs
● Valsartan
○ Dosis de inicio 40 mg cada 12 hs y dosis objetivo 160 mg cada 12 hs
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on
Clinical Practice Guidelines
2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, ESC Clinical Practice Guidelines, 25 Aug 2021
13. Betabloqueantes
● ↓ mortalidad y probabilidad de hospitalización
● ↓ tono adrenergico
○ ↓ consumo de O2
■ Mejora contractilidad ventricular
○ Prevención y reversión de remodelación cardiaca
■ ↓ stress parietal
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical
Practice Guidelines
2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, ESC Clinical Practice Guidelines, 25 Aug 2021
14. Betabloqueantes
● Solo 3 farmacos recomendados (Nivel 1-A)
○ Carvedilol - Dosis inicial de 3.125 mg cada 12 hs y dosis objetivo de
25 mg cada 12 hs
■ Mejora sensibilidad a insulina*
○ Bisoprolol - Dosis inicial de 1.25 mg cada 24 hs y dosis objetivo de 10
mg cada 24 hs
*Nguyen LV, Ta QV, Dang TB, Nguyen PH, Nguyen T, Pham TVH, Nguyen TH, Baker S, Le Tran T, Yang DJ, Kim KW, Doan KV. Carvedilol improves glucose tolerance and insulin
sensitivity in treatment of adrenergic overdrive in high fat diet-induced obesity in mice. PLoS One. 2019 Nov 4;14(11):e0224674. doi: 10.1371/journal.pone.0224674. PMID: 31682617;
PMCID: PMC6827914.
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical
Practice Guidelines
2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, ESC Clinical Practice Guidelines, 25 Aug 2021
Poole-Wilson PA, Swedberg K, Cleland JG, Di Lenarda A, Hanrath P, Komajda M, Lubsen J, Lutiger B, Metra M, Remme WJ, Torp-Pedersen C, Scherhag A, Skene A; Carvedilol Or
Metoprolol European Trial Investigators. Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European
Trial (COMET): randomised controlled trial. Lancet. 2003 Jul 5;362(9377):7-13. doi: 10.1016/S0140-6736(03)13800-7. PMID: 12853193.
15. Betabloqueantes
○ Metoprolol - Dosis inicial de 12.5 mg cada 24 hs y dosis objetivo de
200 mg cada 24 hs
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical
Practice Guidelines
2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, ESC Clinical Practice Guidelines, 25 Aug 2021
16. Antagonistas de los receptores de mineralocorticoides
● Están recomendados por la reducción en mortalidad y morbilidad
(Nivel 1-A)
● Efecto antifibrótico sobre el miocardio
○ ↓Aldosterona que estimula la formación de colágeno y disminución de la
actividad de los fibroblastos
○ ↓Stress oxidativo
● ↓ stress parietal miocárdico por efecto diurético
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical
Practice Guidelines
2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, ESC Clinical Practice Guidelines, 25 Aug 2021
17. Antagonistas de los receptores de mineralocorticoides
● Suspender si K > 5.5 mEq/L mantenido (Nivel 3 B-NR)
● Suspender si creatinina aumenta > 2.5 mg/dl en ♂y >2
mg/dl en ♀
● Contraindicados en TFG < 30ml/min
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical
Practice Guidelines
2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, ESC Clinical Practice Guidelines, 25 Aug 2021
18. Antagonistas de los receptores de mineralocorticoides
● Espironolactona
○ Dosis de inicio 25 mg cada 24 hs y dosis objetivo de 50 mg cada 24 hs
○ Efecto antiandrogénico
■ Ginecomastia
■ Impotencia
■ Sangrado vaginal
● Eplerenona
○ Dosis de inicio 25 mg cada 24 hs y dosis objetivo de 50 mg cada 24 hs
○ Efecto antimineralocorticoide selectivo
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical
Practice Guidelines
2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, ESC Clinical Practice Guidelines, 25 Aug 2021
19. Antagonistas de los receptores de mineralocorticoides
● Quelantes de K podrían ser una opción para reducción de
hiperkalemia
○ Ciclosilicato de Circonio sodico 10 gr cada 8 hs*
○ Kayexalate (poliestireno sulfato) 15 gr cada 24 a 8 hs&
■ Uso concomitante con lactulosa para evitar constipación
● Suspender ARM si diarrea y/o vómitos
*Kosiborod M, Rasmussen HS, Lavin P, et al. Effect of Sodium Zirconium Cyclosilicate on Potassium Lowering for 28 Days Among Outpatients With Hyperkalemia: The HARMONIZE
Randomized Clinical Trial. JAMA. 2014;312(21):2223–2233. doi:10.1001/jama.2014.15688
&Parks M, Grady D. Sodium polystyrene sulfonate for hyperkalemia. JAMA Intern Med. 2019;179(8):1023-1024. doi:10.1001/jamainternmed.2019.1291 [PubMed 31180445]
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical
Practice Guidelines
20. Inhibidores de SGLT2
● ↓ necesidad de hospitalización y mortalidad
● No importa si el paciente es diabetico
● Recomendados:
○ Dapagliflozina a dosis de 10 mg cada 24 hs
○ Empagliflozina a dosis de 10 mg cada 24 hs
● Efecto diurético por pérdida de Na
● ↓ discretamente niveles de K
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical
Practice Guidelines
2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, ESC Clinical Practice Guidelines, 25 Aug 2021
21. Journal of Thoracic and Cardiovascular Surgery, March 02, 2021
Glucosa Ácidos grasos
Glucosa Ácidos
grasos
Cetonas
Cetonas
Insuficiencia cardiaca
Mantención del gasto cardiaco
Terapia con inhibidores SGLT2
BCAA: Aminoácido
ramificados
22. Inicio y llegada a dosis objetivo
McMurray JJV, Packer M. How Should We Sequence the Treatments for Heart Failure and a reduced Ejection Fraction? Circulation 2021; 143:875-877
23. Inicio y llegada a dosis objetivo
Protocolo STRONG-HF
Alta con 1/2 dosis optima
Semana 1 post alta control
Semana 2 post alta si buena tolerancia se sube a dosis optima
Semana 3 control
Semana 6 control
Mebazaa A, Davison B, Chioncel O, Cohen-Solal A, Diaz R, Filippatos G, Metra M, Ponikowski P, Sliwa K, Voors AA, Edwards C, Novosadova M, Takagi K, Damasceno A, Saidu H, Gayat E, Pang PS, Celutkiene
J, Cotter G. Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): a multinational, open-label, randomised, trial. Lancet. 2022 Dec
3;400(10367):1938-1952. doi: 10.1016/S0140-6736(22)02076-1. Epub 2022 Nov 7. PMID: 36356631.
24. Hidralazina + dinitrato de isosorbide
● ↓mortalidad, morbilidad y síntomas en pacientes afrodescendientes con
terapia optima y NYHA III o IV (Nivel 1-A)
● ↓mortalidad y morbilidad en paciente renales que no pueden utilizar
inhibidores del sistema renina angiotensina (Nivel 2b-C-LD)
● Hidralazina dosis de inicio 25 mg (37.5 mg) cada 8 hs y dosis objetivo de 50 mg
(75 mg) cada 8 hs
● Dinitrato de isosorbide dosis de inicio 20 mg cada 8 hs y dosis objetivo de 40
mg cada 8 hs
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical
Practice Guidelines
2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, ESC Clinical Practice Guidelines, 25 Aug 2021
26. Diureticos
● Están recomendados en paciente con retención hídrica para
alivio sintomático
○ Nivel 1 B-NR
● La adición de diuréticos tiazídicos está recomendado cuando
no se alcanza resolución de síntomas congestivos con
diuréticos de asa en dosis moderadas a altas
○ Nivel 1 B-NR
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical
Practice Guidelines
2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, ESC Clinical Practice Guidelines, 25 Aug 2021
27. Diureticos
● Furosemida
○ 20 a 40 mg cada 24 a 12 hs, dosis maxima de 600 mg dia
● Metolazona
○ 2.5 mg cada 24 hs, dosis maxima 20 mg al dia
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical
Practice Guidelines
2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, ESC Clinical Practice Guidelines, 25 Aug 2021
28. Inhibidores del canal If
● Ivabradina
○ FEVI < 35% + ritmo sinusal + FC reposo ≥ 70 lpm en tratamiento con β +
ARNi/IECA + ARM
■ ↓hospitalización y muerte cardiovascular (2a-B)
■ Contraindicado en FA
○ FEVI < 35% + ritmo sinusal + FC reposo ≥ 70 lpm que no toleran betabloqueo
(Dar tambien ARNi/IECA)
■ ↓hospitalización y muerte cardiovascular (2a-C)
2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, ESC Clinical Practice Guidelines, 25 Aug 2021
29. Hierro endovenoso
● Hierro carboximaltosa 15 mg/kg (Máximo 1g):
○ Pacientes sintomáticos + FEVI <45% + Ferritina de 100 a 299 ng/ml + Sat. transferrina <
20% (2a-A)
■ Mejora síntomas de ICC, capacidad para ejercicio y calidad de vida
○ Pacientes recientemente hospitalizados + FEVI <50% + Ferritina < 100 ng/ml o Ferritina de
100 a 299 ng/ml + Sat. transferrina < 20% (2a-B)
■ Reduce riesgo de hospitalización
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical
Practice Guidelines
2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, ESC Clinical Practice Guidelines, 25 Aug 2021
30. Hierro endovenoso
Tratamiento de la ferropenia con Carboximaltosa Férrica - Dosis y administración, https://www.cardioteca.com/ferropenia-dosis-ferinject-
administracion-carboximaltosa-ferrica.html