Heart failure
Refer to local guidelines for support on the management of heart failure:
- NHS Ayrshire & Arran (HFrEF, HFmrEF, HFpEF)
- NHS Greater Glasgow & Clyde
- NHS Lanarkshire
SIGN 147: Chronic Heart Failure NICE CG106: Chronic Heart Failure in Adults
Optimal treatment aims to establish patients on all four classes of disease modifying medications at target or maximally tolerated doses. These should be prescribed in line with any local guidance.
Sacubitril + Valsartan (Angiotensin Receptor-Neprilysin inhibitor) or ramipril (Angiotensin-Converting Enzyme inhibitor) or candesartan (Angiotensin-II receptor antagonist).
Beta blocker – bisoprolol or carvedilol.
Mineralocorticoid Receptor Antagonist (MRA) – spironolactone or eplerenone for patients who develop gynaecomastia with spironolactone.
Sodium-Glucose Cotransporter-2 (SGLT2) inhibitor – dapagliflozin.
Prescribing Notes:
- Patients on SGLT2 inhibitors should be given advice on genitourinary infections and stopping treatment during acute, dehydrating intercurrent illness. A Medicines Sick Day Guidance card is available.
- Diabetic ketoacidosis is a rare but life-threatening side-effect of SGLT2 inhibitors. For more information refer to MHRA Drug Safety Update (April 2016) SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis.
- Dapagliflozin is not recommended for the management of heart failure in patients with type 1 diabetes due to the lack of safety and efficacy data for that population.
- Beta-blockers may cause bronchospasm; use with caution and under specialist supervision in patients with a history of asthma.
History Notes
27/05/2026
Regional formulary chapter launched.
Optimal treatment aims to establish patients on all four classes of disease modifying medications at target or maximally tolerated doses. These should be prescribed in line with any local guidance.
Ramipril (Angiotensin-Converting Enzyme inhibitor) or candesartan (Angiotensin-II receptor antagonist).
Beta blocker – bisoprolol or carvedilol.
Mineralocorticoid Receptor Antagonist (MRA) – spironolactone or eplerenone for patients who develop gynaecomastia with spironolactone.
Sodium-Glucose Cotransporter-2 (SGLT2) inhibitor – dapagliflozin.
Prescribing Notes:
- Patients on SGLT2 inhibitors should be given advice on genitourinary infections and stopping treatment during acute, dehydrating intercurrent illness. A Medicines Sick Day Guidance card is available.
- Diabetic ketoacidosis is a rare but life-threatening side-effect of SGLT2 inhibitors. For more information refer to MHRA Drug Safety Update (April 2016) SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis.
- Dapagliflozin is not recommended for the management of heart failure in patients with type 1 diabetes due to the lack of safety and efficacy data for that population.
- Beta-blockers may cause bronchospasm; use with caution and under specialist supervision in patients with a history of asthma.
History Notes
27/05/2026
Regional formulary chapter launched.
Optimal treatment includes treating co-morbidities and any symptom management.
Sodium-Glucose Cotransporter-2 (SGLT2) inhibitor – dapagliflozin.
Prescribing Notes:
- Patients on SGLT2 inhibitors should be given advice on genitourinary infections and stopping treatment during acute, dehydrating intercurrent illness. A Medicines Sick Day Guidance card is available.
- Diabetic ketoacidosis is a rare but life-threatening side-effect of SGLT2 inhibitors. For more information refer to MHRA Drug Safety Update (April 2016) SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis.
- Dapagliflozin is not recommended for the management of heart failure in patients with type 1 diabetes due to the lack of safety and efficacy data for that population.
History Notes
27/05/2026
Regional formulary chapter launched.
Consider a loop diuretic in all patients with signs or symptoms of fluid retention.
Bumetanide may be an option in those patients that are not responding to furosemide (1mg bumetanide is equivalent to 40mg furosemide).
For patients with resistant oedema. Xaqua tablets are not interchangeable with other metolazone preparations and should be prescribed by brand name.
For patients requiring potassium sparing diuretics. Note that amiloride is a less cost-effective preparation compared to the combination of co-amilofruse.
History Notes
27/05/2026
Regional formulary chapter launched.
For patients in sinus rhythm (SR), heart rate ≥75bpm and LVEF <35% in combination with standard therapy, or where beta blockers are contraindicated or not tolerated.
For patients with symptomatic heart failure, in sinus rhythm and LVEF <40%.
For patients intolerant of Angiotensin Receptor-Neprilysin inhibitor, Angiotensin-Converting Enzyme inhibitor or Angiotensin-II receptor antagonist.
Prescribing Notes:
- Some of these drugs may be given in combination, refer to local and national guidelines on management of heart failure for more information.
- Ivabradine 5mg tablets are scored and can be divided into two equal doses if 2.5mg doses are required. This is more cost effective than using 2.5mg tablets.
History Notes
27/05/2026
Regional formulary chapter launched.