1 | HF MTAC Protocol 2nd Edition 2024

Second Edition (October 2024)

This is a publication of
Pharmaceutical Services Programme
Ministry of Health Malaysia
Lot 36, Jalan Profesor Diraja Ungku Aziz,
46200 Petaling Jaya, Selangor, Malaysia
Tel: 603 – 7841 3200
Website: [Link]

All rights reserved.

Enquiries are to be directed to the address above. The publisher reserves copyright
and renewal on all published materials. Permission is hereby granted to reproduce
information contained herein provided that such reproduction be given due
acknowledgement and shall not modify the text.
This edition was produced after reviewing the most recent evidence at the time of
development. Every healthcare provider is responsible to make appropriate clinical
judgement in consideration of each patient's condition at presentation based on
treatment options available locally.

2 | HF MTAC Protocol 2nd Edition 2024

 FOREWORD
The Pharmaceutical Services Programme, Ministry of
Health Malaysia is currently offering Heart Failure
Medication Therapy Adherence Clinic (MTAC) services in a
total of eight hospitals to cater for patients from seven
different states, namely Johor, Melaka, Penang, Perak
Sarawak and Selangor as well as the federal territory of
Kuala Lumpur. This service, in collaboration with doctors
and other healthcare providers, seeks to improve patients’
adherence to their medication to lower the risk for
readmission among heart failure patients and subsequent
mortality.
Indeed, this effort represents a significant advancement in managing heart failure. By
enhancing patients' understanding of their medications and identifying pharmaceutical
care issues, Heart Failure MTAC improves the quality of service delivery and ultimately
enhances patients' quality of life. This collaborative model empowers individuals to
engage actively in their care, leading to better health outcomes and a more fulfilling
daily experience.
As the Heart Failure MTAC Protocol was first published by the Pharmacy Practice &
Development Division, Ministry of Health Malaysia in 2018, now almost six years later,
it is timely that the protocol be updated to consider new development in the
management of heart failure based on the latest evidence.
Indeed, I would like to congratulate the task force and editorial team for their
contribution and commitment in producing this publication. May this protocol be a
useful guide in the establishment of a standardized provision of Heart Failure MTAC
service in all Ministry of Health facilities.

Thank you.

WAN NORAIMI BINTI WAN IBRAHIM

Director
Pharmacy Practice & Development Division
Pharmaceutical Services Programme
Ministry of Heath Malaysia

3 | HF MTAC Protocol 2nd Edition 2024

 EDITORIAL BOARD

Advisors
Wan Noraimi binti Wan Ibrahim
Pharmacy Practice and Development Division, Ministry of Health

Syahida binti Che Embi

Pharmacy Practice and Development Division, Ministry of Health

Editors
Dr. Sahimi binti Mohamed
Hospital Sultan Idris Shah Serdang

Dr. Aliza binti Alias

Pharmacy Practice and Development Division, Ministry of Health

Chuah Sim Mei

Pharmacy Practice and Development Division, Ministry of Health

4 | HF MTAC Protocol 2nd Edition 2024

 Task Force Members
Chairperson
Ooi Soon Choo
Hospital Pulau Pinang

Members (in alphabetical order)

Chan Pooi Yee
Hospital Raja Permaisuri Bainun

Chia Pooi Yin

Hospital Pulau Pinang

Tang Jiaa Yinn

Hospital Kuala Lumpur

Thanujah Kaisbain
Hospital Sultanah Aminah

Wan Nurul Huda binti Wan Hassan

Hospital Sultan Idris Shah Serdang

External Reviewers
Dr. Kim Heng Shee
Cardiologist
Hospital Sultanah Aminah

Dr. Chua Ping Lik

Cardiologist
Hospital Sultan Idris Shah Serdang

5 | HF MTAC Protocol 2nd Edition 2024

 CONTENTS
Introduction.............................................................................................................................................. 7
Objectives................................................................................................................................................ 8
Scope of Service ..................................................................................................................................... 8
Manpower Requirement .......................................................................................................................... 8
Appointment ............................................................................................................................................ 9
Procedures .............................................................................................................................................. 9
A. Workflow...................................................................................................................................... 9
B. Patient Recruitment Criteria ........................................................................................................ 9
C. Clinic Operation ....................................................................................................................... 9
First Visit.......................................................................................................................................... 9
Second and Subsequent Visits ..................................................................................................... 10
D. Responsibilities of the Pharmacist ........................................................................................ 11
E. Patient Discharge Criteria ......................................................................................................... 12
Documentation ...................................................................................................................................... 12
Quality Assurance / Outcome Measurements ...................................................................................... 13
References ............................................................................................................................................ 14
Appendices ........................................................................................................................................... 16
Appendix 1 : HF MTAC Workflow (First Visit) ................................................................................... 16
Appendix 2 : HF MTAC Workflow (Subsequent Visit) ....................................................................... 17
Appendix 3 : HF MTAC Pharmacotherapy Review Form – First Visit (HF MTAC/F1) ...................... 18
Appendix 4 : HF MTAC Pharmacotherapy Review Form –Laboratory Investigation (HF MTAC/F2)
.......................................................................................................................................................... 19
Appendix 5 : HF MTAC Pharmacotherapy Review Form – Continuation (HF MTAC/F3) ................ 20
Appendix 6 : Education Module for Heart Failure Patients ............................................................... 22
Appendix 7 : Pharmacotherapy in Heart Failure ............................................................................... 24
Appendix 8 : Angiotensin-converting enzyme inhibitor (ACE-i) / Angiotensin Receptor Blocker
(ARB)................................................................................................................................................. 33
Appendix 9 : Angiotensin Receptor-Neprilysin Inhibitor (ARNI) ........................................................ 35
Appendix 10 : β-Blockers .................................................................................................................. 36
Appendix 11 : Sodium-Glucose Co-Transporter 2 Inhibitors (SGLT2-i) ........................................... 38
Appendix 12 : Mineralocorticoid Receptor Antagonist ...................................................................... 40
Appendix 13 : Diuretics ..................................................................................................................... 41
Appendix 14 : Ivabradine .................................................................................................................. 44
Appendix 15 : Salt Content in Common Malaysian Foods ............................................................... 46

6 | HF MTAC Protocol 2nd Edition 2024

Introduction

Heart failure (HF) is a clinical syndrome caused by the inability of the heart to pump
sufficient blood to meet the metabolic requirements of the body1. This syndrome is
usually associated with high mortality, frequent hospitalization, poor quality of life,
multiple co-morbidities and a complex therapeutic regimen1. The prevalence of heart
failure is increasing worldwide, including Malaysia, due to the ageing population,
improved survival of people with ischemic heart disease and better treatment
options1,2,3,4.

In an analysis carried out using primary care records in the UK, the overall survival
rates for the heart failure group were 81.3%, 51.5% and 29.5% at 1, 5 and 10 years
respectively5. Heart failure is also an important cause of hospitalization accounting for
about 10% of all medical admissions in Malaysia6. About 50% of patient with recent
heart failure hospitalization can have readmission within six (6) months post
discharge7. In another study, readmission to hospital and death, respectively, occurred
following 67.4% and 35.8% of hospitalizations for heart failure within one year of
hospital discharge8. Poor adherence to drug therapy is a significant challenge in
achieving the desired therapeutic outcome among patients and is associated with
hospital readmissions9. The involvement of pharmacists in heart failure patient care
has been proven effective in reducing the risk of hospitalization10.

The Heart Failure Medication Therapy Adherence Clinic (HF MTAC) is an ambulatory
care service conducted by pharmacists in collaboration with doctors and other
healthcare providers with the aim of improving heart failure care in patient. This
protocol serves as a guide to establish and provide a standardized practice in all HF
MTAC service in all Ministry of Health (MOH) facilities, including hospitals or health
clinics.

7 | HF MTAC Protocol 2nd Edition 2024

Objectives

1. The objectives of HF MTAC are to:

a. Enhance patient’s adherence to heart failure pharmacotherapy and non-
pharmacological interventions.
b. Reduce mortality and improve quality of life of heart failure patients.
c. Reduce unscheduled emergency department visits or hospitalizations of
heart failure patient due to acute decompensation.
d. Provide consultative service to doctors on evidence-based heart failure
pharmacotherapy and related issues.
e. Collaborate with doctors & other healthcare professionals in the
management of heart failure patient.

Scope of Service

1. The HF MTAC service should operate in a designated clinic area.

2. The activities in the clinic should include assessment of patient’s condition,

medication history taking, counselling and making recommendations for
dosage adjustment or perform medication reconciliation.

3. A plan of action for patients to manage their heart failure symptoms should be
developed, if possible.

Manpower Requirement

1. A minimum of two (2) trained pharmacist in a HF MTAC team where at least

one (1) pharmacist will be on duty during HF MTAC.

8 | HF MTAC Protocol 2nd Edition 2024

Appointment

1. All appointments will be scheduled by pharmacists or other health care

providers participating in the clinic.

2. The frequency of HF MTAC visits will be tailored to each patient's individual

needs, determined by their initial assessment. Patients identified as high-risk
(e.g., recently hospitalized due to heart failure decompensation) will be
scheduled for more frequent follow-ups.

Procedures

A. Workflow

1. The workflow of HF MTAC is as shown in Appendix 1 and Appendix 2

B. Patient Recruitment Criteria

1. Patients who fulfil any of the following may be enrolled into HF MTAC :
a. Newly diagnosed with heart failure
b. Poor left ventricular ejection fraction (LVEF) ≤ 40%
c. Recently admitted to hospital due to acute decompensation of heart
failure (within 90 days after hospital discharge)
d. Require more extensive heart failure management of up-titrated
evidence-based pharmacotherapy
e. Diagnosed with heart failure and has a poor compliance to medications
or fluid intake

C. Clinic Operation

First Visit

1. The pharmacist will introduce himself/herself

9 | HF MTAC Protocol 2nd Edition 2024

 2. During the first visit, the pharmacist will perform an initial assessment
of the patient by using HF MTAC forms (refer Appendix 3, 4 & 5), which
includes:
a. Demographic data
b. Diagnosis
c. Past medical / Surgical history
d. Investigation / Imaging
e. Allergies / Adverse drug reaction (ADR)
f. Social history (Smoking, alcohol, drug abuse, pregnancy)
g. Laboratory investigations
h. Vital signs
i. Diet and lifestyle
j. Current medications
k. Assess patient’s understanding and knowledge on medication,
disease and self-care knowledge of heart failure management
l. Identify pharmaceutical care issues (PCIs)
3. Patient’s prescription or appointment book may be tagged to aid in
identifying the patient as being enrolled into HF MTAC.
4. Patients should be given a booklet/ pamphlet i.e. a book to be used by
the patient as a reference and to record important information such as
daily monitoring of vital signs (blood pressure, heart rate, presence of
shortness of breath and body weight measurement).

Second and Subsequent Visits

1. Follow-up sessions should be scheduled based on the patient’s next

clinic or pharmacist’s appointment date, patient’s need, current health
status and medication refills appointment (minimum four (4) follow-ups
per year).
2. The pharmacist will review / assess on the following and document in
the HF MTAC/F3 form (refer Appendix 5) :
a. Vital signs and other physical parameters
b. Any recent hospital admission(s)

10 | HF MTAC Protocol 2nd Edition 2024

 c. Allergies / ADR
d. Signs and symptoms of disease
e. Diet & lifestyle (e.g. salt and water intake, smoking and alcohol
intake)
f. Counselling modules
g. Other issues and action plans
h. Patient’s knowledge and understanding on medications
i. Patient’s compliance to medications
j. Medication dosage adjustments or change in medication regimen
(if any)
k. The next HF MTAC appointment date.

D. Responsibilities of the Pharmacist

1. The pharmacist during HF MTAC should :

a. Educate the patient and their caregiver(s) about heart failure and the
pharmacotherapy involved
b. Discuss any clinically significant laboratory investigation result with the
prescriber
c. Identify and report of any adverse drug reactions / allergies
d. Discuss any potential interactions among the prescribed medications
with the prescriber
e. Discuss any suggested change in medication dosage or regimen with
the prescriber. All initiation of treatment and dose changes must be
prescribed by a doctor. The responsibility for commencing a patient on
any therapy is with the attending doctor. The pharmacist may, under
local policies and Head of Facilities’ approval, be authorized to transcribe
existing medication orders and, in some limited circumstances, adjust
medication dosages (if necessary/if needed/if applicable)
f. Explain to the patient regarding any changes to the current regimens, as
agreed by the prescriber

11 | HF MTAC Protocol 2nd Edition 2024

 g. Educate the patient on medications which require self-dosage
adjustment, if applicable. The list of medications for patients to self-
adjust dosage is based on local policy/approval
h. Ensure that adequate medications are being prescribed until the next
appointment date
i. Provide comprehensive counselling using Education Modules for Heart
Failure Patients (refer Appendix 6). The modules will be delivered
according to the patient’s understanding and knowledge at every visit
(approximately 15-20 minutes/session)

E. Patient Discharge Criteria

1. The patient may be considered for discharge from HF MTAC if any of the
following is fulfilled :
a. The patient is stable with optimized medications
b. Requested to be discharged / Defaulted for more than 6 months

Documentation

1. All relevant data is to be recorded using designated forms and kept in the
patient’s profile and/or case notes.
2. The list of documents are as follows :
a. HF MTAC/F1 – Heart Failure Medication Therapy Adherence Clinic
Pharmacotherapy Review Form - First Visit (refer Appendix 3)
b. HF MTAC/F2 – Heart Failure Medication Therapy Adherence Clinic
Pharmacotherapy Review Form - Laboratory Investigation
(refer Appendix 4)
c. HF MTAC/F3 – Heart Failure Medication Therapy Adherence Clinic
Pharmacotherapy Form - Continuation (refer Appendix 5)

12 | HF MTAC Protocol 2nd Edition 2024

Quality Assurance / Outcome Measurements

1. This service should be continuously assessed to ensure that patients receive

optimal care and that any shortfalls are able to be detected from time to time.
2. Outcome measurements for the service may include improvement in Left
Ventricular Ejection Fraction (LVEF), New York Heart Association (NYHA)
functional classification, number of unscheduled visits to healthcare service,
hospital admission, mortality and quality of life.

13 | HF MTAC Protocol 2nd Edition 2024

References

1. Dipiro JT, Talbert RL, et al. Pharmacotherapy: A Pathophysiologic Approach, 8 th

ed. USA: McGraw-Hill; 2011.

2. Lee S, Kurana R, and Leong KTG. Heart failure in Asia: the present reality and
future challenges. European Heart Journal Supplements (2012) 14, Supplement A,
A51-A52.

3. Guo Y, Lip GYH and Banerjee A. Heart Failure in East Asia. Current Cardiology
Reviews (2013) 9,112-122.

4. Lam CSP, Anand I, Zhang S, et al. Asian Sudden Cardiac Death in Heart Failure
(ASIAN-HF) registry. European Journal of Heart Failure (2013) 15, 928-936.

5. Taylor CJ, Ryan R, Nichols L, et al. Survival following a diagnosis of heart failure
in primary care. Family Practice (2017) 34(2), 161-168.

6. Chin SP, Sapari S, How SH and Sim KH. Managing Congestive Heart Failure in a
General Hospital in Malaysia. Are We Keeping Pace With Evidence?. Med J Malaysia
(2006 Aug) 61(3), 278-283.

7. Butler J, Kalogeropoulos A. Worsening heart failure hospitalization epidemic we

do not know how to prevent and we do not know how to treat! J Am Coll Cardiol (2008)
52, 435-7.

8. Dharmarajan K, Hsieh AF, Kulkarni VT, et al. Trajectories of risk after

hospitalization for heart failure, acute myocardial infarction, or pneumonia:
retrospective cohort study. BMJ (2015) 350, h411.

9. Cole JA, Norman H, Weatherby LB, et al. Drug copayment and adherence in
chronic heart failure: effect on cost and outcomes. Pharmacotherapy (2006)
26(8),1157-1164.

10. Koshman SL, Simpson SH, Tsuyuki RT. Pharmacist Care of Patients With Heart
Failure: A Systematic Review of Randomized Trials. Arch Intern Med. (2008 Apr)
14,168(7):687-694.

11. Malaysian Clinical Practice Guidelines: Management of Heart Failure 2023 (5th
edition).

14 | HF MTAC Protocol 2nd Edition 2024

12. McDonagh T.A., Metra M., Adamo M., et al. "2021 ESC Guidelines for the
diagnosis and treatment of acute and chronic heart failure: Developed by the Task
Force for the diagnosis and treatment of acute and chronic heart failure of the
European Society of Cardiology (ESC) With the special contribution of the Heart
Failure Association (HFA) of the ESC". Eur Heart J 2021;[Link] 3599-3726

13. Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ et al. 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. Circulation. 2022;145:e895-e1032

14. Maddox, T, Januzzi, J, Allen, L. et al. 2024 ACC Expert Consensus Decision
Pathway for Treatment of Heart Failure With Reduced Ejection Fraction: A Report of
the American College of Cardiology Solution Set Oversight Committee. J Am Coll
Cardiol. 2024 Apr, 83 (15) 1444–1488.

15. Sindone AP, De Pasquale C, Amerena J, Burdeniuk C, Chan A, Coats A, et

al. Consensus statement on the current pharmacological prevention and management
of heart failure. Med J Aust 2022;217:212-7. 10.5694/mja2.51656

16. Engelhardt K, Ferguson M, Rosselli JL. Prevention and management of genital

mycotic infections in the setting of sodium-glucose cotransporter 2 inhibitors
[published online August 18, 2020 ]. Annals of Pharmacotherapy.
[Link]/10.1177/1060028020951928

17. South London Cardiovascular Disease Medicines Working Group on behalf of the
SEL Integrated Medicines Optimisation Committee, South East London guidance on
the pharmacological management of Heart Failure in adults, Last reviewed and
approved: October 2023, Available at: [Link]
odn/workstreams/heart-failure/hf-prescribing-guidance/

18. Procoralan® (ivabradine 5 and 7.5 mg film-coated tablets): summary of product

characteristics. London: European Medicines Agency; 2013.

15 | HF MTAC Protocol 2nd Edition 2024

Appendices

Appendix 1 : HF MTAC Workflow (First Visit)

Registration Nurse

Vital signs and body weight

measurement Nurse

Recruitment & baseline assessment* Doctor /Pharmacist

Review and recommendations

Pharmacist

Counselling & education

Based on pt’s understanding & needs during visit Pharmacist

Feedback / suggestion to the doctor on

dosage adjustment / new drug initiation Pharmacist

Any changes to Counsel on latest

medication? Yes medication changes Pharmacist
to patient

Document treatment plan and schedule

for next visit Pharmacist

End *Forms to be used : HF MTAC/F1, F2, F3

16 | HF MTAC Protocol 2nd Edition 2024

Appendix 2 : HF MTAC Workflow (Subsequent Visit)

Registration Nurse

Vital signs and body weight

measurement Nurse

Assessment and review* Doctor /Pharmacist

Reinforcement, counseling & education

(modules) Pharmacist
Based on pt’s understanding & needs during visit

Feedback / suggestion to the doctor on dosage

adjustment / new drug initiation Pharmacist

Counsel on latest
Any changes to medication changes Pharmacist
Yes

medication? to patient

Document treatment plan and schedule for Pharmacist

next visit

End *Forms to be used : HF MTAC/F2, F3

17 | HF MTAC Protocol 2nd Edition 2024

Appendix 3 : HF MTAC Pharmacotherapy Review Form –
First Visit (HF MTAC/F1)
Date of recruitment
Date of discharge
Reason(s) of discharge

Heart Failure Medication Therapy Adherence Clinic (HF MTAC)

FIRST VISIT FORM
Part 1: First Visit Form
Patient’s Profile
Name: IC number:

Age (years): Gender: M / F Contact number:

Vaccination (if any): Occupation: □ Pensioner – JPA
□ Pneumococcal Vaccine - Date: □ Pensioner –State/Badan Berkanun
□ Influenza Vaccine - Date:
□ Gov Servant
Last hospital admission date:

Diagnosis / Past Medical / Surgical:

Investigation / Imaging:

Allergies: Adverse Drug Reaction (ADR):

 NKDA
 Yes, please specify _______________
 Allergic card: Yes / No

Social History
Smoking Alcohol Drug Abuse Pregnant
 No  No  No  No
 Yes ____/day  Yes________/day  Yes  Yes ______
 Ex-smoker  Ex-alcoholic
__________

Pharmacist notes
• Reason of recruitment into HFMTAC:
• Any other hospital or KK follow up: No / Yes ___________________

Pharmacist’s Stamp & Signature _______________________

18 | HF MTAC Protocol 2nd Edition 2024

Appendix 4 : HF MTAC Pharmacotherapy Review Form –
Laboratory Investigation (HF MTAC/F2)

A) PATIENT’S PROFILE
Name: IC Number:

B) LABORATORY INVESTIGATIONS
DATE
WBC (4-10 x10³/µl)
FBC

Hb (12-15g/dl)
Platelet (150-410 x10³/µl)

Urea (2.76-8.07mmol/l)
Na (136-145mmol/l)
K (3.4-4.5mmol/l)
Renal Profile

Cl (98-107mmol/l)
Creat (44-80mmol/l)
CrCl
eGFR

Albumin (35-52g/l)
AST (10-50u/l)
LFT

ALP (40-129u/l)
ALT (10-50u/l)
Bilirubin (<21umol/l)

TC (<5.2mmol/l)
Lipid Profile

HDL (>1.2mmol/l)
LDL (<3.0mmol/l)
TG (<1.7mmol/l)

T4 (12-22)
TFT

TSH (0.27-4.20)
INR
FPG (3.9-6.0mmol/l)
HbA1c (≤6.5%)
NT - proBNP < 100 pg/ml
Iron 11.6-31.3umol/L
Ferritin 21.8-274.4umol/L
Iron studies

UIBC 12.4-43.0umol/L
TIBC 40.8-76.6umol/L
TSAT (%) >20%
Folate 7.0-46.4nmol/L
Vitamin B 12 138-652pmol/L
Others

*Reference ranges derived from local hospital laboratory which may varies between different facilities.

19 | HF MTAC Protocol 2nd Edition 2024

Appendix 5 : HF MTAC Pharmacotherapy Review Form –
Continuation (HF MTAC/F3)

Heart Failure Medication Therapy Adherence Clinic (HF MTAC)

CONTINUATION FORM

Part 2(a): Continuation Form

Date : Visit No :
Name :
IC No. / Registration No : Patient was seen :  Before doctor’s visit  After doctor’s visit

Vital signs and other physical parameters (if available):

BP : Previous body weight (kg) : 6MWT : INR :
Heart rate : Current body weight (kg) : NTproBNP :

Pharmaceutical care issues (PCI):

No. Issues
1. Recent Hospital admission: No / Yes
Date of admission: ___________ ; Reason of admission: ___________________________
2. Allergy / ADR:

3. Sign / symptoms of disease

• NYHA Classification: I / II / III / IV • Pedal odema:
• Sleep with _____ pillows • Lethargy:
• SOB: • Dizziness:
• Reduced effort tolerance: • Chest pain:
• PND: • Bleeding tendency (if applicable):
• Nocturnal cough: • Others:
4. Diet / Lifestyle
• Fluid: Compliant to ROF: Yes / No _________________________ □ Counsel patient on the proper to measure ROF
• Diet (restriction of salt intake): Yes / No _________________ □ Counsel patient on the importance of salt restrictions
• Exercise: Yes / No____________________ □ Counsel patient the importance of making light exercise daily routine
• Smoking /Alcohol Intake: Yes / No ______________________________ □ Counsel patient for smoking cessation
5. Counselling modules:
□ Module 1: Overview of Heart Failure
□ Module 2: Causes of Heart Failure
□ Module 3: Sign and symptoms of Heart Failure
□ Module 4: Pharmacotherapy of HF (Group of medications counselled:______________________________________)
□ Module 5: Non pharmacotherapy approach
□ Reassessment of previous counselled module
□ Others:
6. Issues / Remarks Action Plans
□ Remind patient for self- monitoring (BP, HR, Body Weight)

20 | HF MTAC Protocol 2nd Edition 2024

Part 2(b): Review of Patient’s Medications and Their Understanding
Medications Current
D F I T Pharmacist’s recommendation Doctor’s Plan
(Please circle) Dose
ACEI: Perindopril / Enalapril / Captopril / Ramipril
ARB: Valsartan / Losartan
ARNI: Sacubitril/Valsartan (Entresto)
Beta blocker:
Bisoprolol / Carvedilol / Metoprolol
Aldosterone Antagonist:
Spironolactone / Eplerenone
SGLT2 inhibitors:
Empagliflozin / Dapagliflozin
Loop Diuretic: Furosemide / Bumetanide
Thiazide: Hydrochlorothiazide / Metolazone
Ivabradine
Digoxin
Potassium Chloride

CCB: Amlodipine / Felodipine

Vasodilator:
Isosorbide dinitrate / mononitrate / SL GTN
Anti-angina agents:
Trimetazidine / Trimetazidine MR
Antiplatelet agents: Aspirin / Cardiprin
Clopidogrel / Ticagrelor / Ticlopidine
Anticoagulants:
Warfarin / Dabigatran / Rivaroxaban / Apixaban /
Edoxaban
Lipid-modifying agents:
Simvastatin / Atorvastatin / Rosuvastatin
Ezetimibe

Other Medications:

OTC/ TCM:

(a) DFIT Score (%) : (b) Compliance to medications (MYMAAT/ other adherence tools) :
Pharmacist’s notes :

Next HF MTAC appointment:

D: Dose F: Frequency I: Indication T: Method of Administration

Pharmacist’s Stamp & Signature : ________________ Doctor’s Stamp & Signature: __________________

21 | HF MTAC Protocol 2nd Edition 2024

Appendix 6 : Education Module for Heart Failure Patients
Module 1: Overview of Heart Failure
⮚ Introduction to heart failure
✔ What is a normal heart?
✔ What is heart failure?

Module 2: Causes of Heart Failure

⮚ Causes of heart failure
✔ What is the likely cause of your heart failure?
✔ What is your heart function (ejection fraction)?

Module 3: Signs and Symptoms of Heart Failure

⮚ Signs and symptoms of heart failure
⮚ Common tests and clinical investigations for heart failure

Module 4: Pharmacotherapy of Heart Failure

⮚ Therapeutic goals:
✔ Reduce mortality and heart failure hospitalization
✔ Reduce signs and symptoms
✔ Increase functional capacities
✔ Increase quality of life
⮚ What are the heart failure
medications?
✔ ACE-Inhibitors / ARBs / ARNI ✔ SGLT2-Inhibitors
✔ Beta blockers ✔ Ivabradine
✔ Diuretics ✔ Digoxin
✔ Aldosterone antagonists ✔ Potassium supplements
⮚ What are the medications to avoid?
🗶 NSAIDs
🗶 Non-DHP Calcium Channel Blockers (e.g. Diltiazem, Verapamil)
🗶 Antiarrhythmic drugs (e.g. Quinidine, Procainamide, Flecainide)
⮚ Medication compliance
✔ Tips for taking all of your medications as prescribed
✔ Use of pillbox, set reminder in mobile phone, etc.
✔ Discuss with prescriber on the possibility of reducing medication frequency
Module 5: Non-Pharmacotherapy Approach
⮚ Physical activity
✔ Lose weight if you are overweight
✔ Maintain ideal body weight
✔ Weigh yourself and look out for swelling

22 | HF MTAC Protocol 2nd Edition 2024

 ⮚ Daily Weight Monitoring
✔ Monitor and record your body weight daily, preferably at the same time or
hour. Any sudden increase in body weight may indicate worsening of your
heart condition, which could be resulting from excess fluid. You should
seek for professional advice if your weight increases by more than 2 kg
over 3 days
⮚ Lifestyle adjustment:
✔ Quit smoking
✔ Avoid/ reduce alcohol intake
✧ Alcoholic intake should be discouraged as it can depress myocardial
contractility and function. If you have established heart failure, the
sheer volume load of alcoholic beverages may worsen your fluid
status.
✔ Practice healthy dietary habits
✧ Reduce salt intake
✧ What is a low-sodium (salt) diet?
✧ How do you follow a low-sodium(salt) diet?
e.g. no added salt on the table, add minimal during cooking and avoid
salty processed food (Appendix 13)
✧ Learn to read food labels
✔ Controlling fluid intake
✧ Restrict daily fluid intake as per doctor’s advice in order to
minimize the risk of acute decompensation due to fluid overload
✔ Possible barriers to follow your treatment plan and what are the ways to
overcome them
✧ Side effects from your medications
✧ Having trouble to follow up in clinic
✧ Lack of time or energy to go exercise
✧ Unable to cook
✧ Experiencing cravings for unhealthy foods that can derail your dietary
goals
✧ Feeling overwhelmed or depressed

23 | HF MTAC Protocol 2nd Edition 2024

Appendix 7 : Pharmacotherapy in Heart Failure 11-14

Pharmacotherapy ANGIOTENSIN-CONVERTING ENZYME ANGIOTENSIN II RECEPTOR ANGIOTENSIN RECEPTOR NEPRILYSIN

INHIBITORS (ACE-i) BLOCKERS (ARB) INHIBITOR (ARNI)

(Refer Appendix 8 for further information) (Refer Appendix 8 for further information) (Refer Appendix 9 for further information)
Goal - Improve symptoms and exercise - Improve symptoms and exercise - Improve symptoms and exercise capacity
capacity capacity - Prevent worsening of HF leading to
- Prevent worsening of HF leading to - Prevent worsening of HF leading to hospital admission
hospital admission hospital admission - Increase survival
- Increase survival - Increase survival
Target Population For all patients with HFrEF ARB is an alternative for patient who - For patients with HFrEF
cannot tolerate ACE-i side effects - Replacement for ACE-i/ ARB or can be
(e.g. dry cough) considered in ACE-i/ARB naïve patient
with HFrEF
Monitoring - RP (1-2 weeks after initiation/ dose - RP (1-2 weeks after initiation/ dose - RP (1-2 weeks after initiation/ dose titration)
Parameters/ titration) titration) - Electrolytes (especially K+)
Investigations - Electrolytes (especially K+) - Electrolytes (especially K+) - BP
- BP - BP - NT-Pro BNP is a more reliable biomarker
than BNP (BNP levels may be falsely
elevated as the drug prevents its
Initial drop in eGFR might be observed but Initial drop in eGFR might be breakdown)
this should not lead to discontinuation of observed but this should not lead to
ACE-i discontinuation of ARB Initial drop in eGFR might be observed but
this should not lead to discontinuation of
ARNI

Initiation/ Titration Refer Appendix 8: ACE-i Refer Appendix 8: ARB Refer Appendix 9: ARNI

24 | HF MTAC Protocol 2nd Edition 2024

 Pharmacotherapy ANGIOTENSIN-CONVERTING ENZYME ANGIOTENSIN II RECEPTOR ANGIOTENSIN RECEPTOR NEPRILYSIN
INHIBITORS (ACE-i) BLOCKERS (ARB) INHIBITOR (ARNI)

(Refer Appendix 8 for further information) (Refer Appendix 8 for further information) (Refer Appendix 9 for further information)
Cautions - Asymptomatic low BP - Asymptomatic low BP - Asymptomatic low BP
- Symptomatic hypotension (dizziness/ - Symptomatic hypotension (dizziness/ - Symptomatic hypotension (dizziness/ light-
light-headedness during initiation may light-headedness during initiation headedness during initiation may improve
improve with time) may improve with time) with time)
- Hyperkalaemia (especially with - Hyperkalaemia (especially with - Hyperkalaemia (especially with concomitant
concomitant use of K+-sparing diuretics concomitant use of K+-sparing use of K+-sparing diuretics & K+
& K+ supplements) diuretics & K+ supplements) supplements)
- Worsening of renal function - Worsening of renal function - Worsening of renal function
- Consider reducing or discontinuing - Consider reducing or - Consider reducing or discontinuing ARNI
ACE-i when SCr remain ≥30% from discontinuing ARB when SCr when SCr remain ≥30% from baseline or
baseline or eGFR reduced ≥25% remain ≥30% from baseline or eGFR reduced ≥25% (after excluding
(after excluding other precipitating eGFR reduced ≥25% (after other precipitating factors) within two
factors) within 2 months from excluding other precipitating months from commencement
commencement factors) within 2 months from - Severe aortic stenosis
- Severe aortic stenosis commencement - A washout period of at least 36 hours when
- Severe aortic stenosis switching from ACE-i is required in order to
minimize the risk of angioedema.
Contraindications - History of angioedema - History of angioedema - History of angioedema
- Bilateral renal artery stenosis - Bilateral renal artery stenosis - Bilateral renal artery stenosis
- Pregnancy/ risk of pregnancy - Pregnancy/ risk of pregnancy - Symptomatic hypotension or SBP <90 mmHg
- Pregnancy/ risk of pregnancy &
breastfeeding period

25 | HF MTAC Protocol 2nd Edition 2024

 Pharmacotherapy ANGIOTENSIN-CONVERTING ENZYME ANGIOTENSIN II RECEPTOR ANGIOTENSIN RECEPTOR NEPRILYSIN
INHIBITORS (ACE-i) BLOCKERS (ARB) INHIBITOR (ARNI)

(Refer Appendix 8 for further information) (Refer Appendix 8 for further information) (Refer Appendix 9 for further information)
Advice to Patients - Explain expected benefits: e.g. - Explain expected benefits: e.g. - Explain expected benefits: e.g. improved
improved symptoms, prevention of improved symptoms, prevention of symptoms, prevention of worsening HF
worsening HF leading to admission, worsening HF leading to admission, leading to admission, increased survival
increased survival increased survival (reduction in both CV & all-cause mortality)
- Symptoms improve within a few weeks - Symptoms improve within a few - Symptoms improve within a few weeks to a
to a few months after starting treatment weeks to a few months after starting few months after starting treatment
- To report any adverse effects treatment - To report any adverse effects
- Avoid NSAIDs (unless essential- - To report any adverse effects - Avoid NSAIDs (unless essential- prescribed
prescribed by physician) - Avoid NSAIDs (unless essential- by physician)
- Avoid salt substitutes high in K+ prescribed by physician) - Avoid salt substitutes high in K+
- Avoid salt substitutes high in K+

ACE-I : angiotensin-converting enzyme inhibitor; ARB : angiotensin II receptor blocker; ARNI : angiotensin receptor neprilysin inhibitor; BP : blood pressure; BNP : B-type
natriuretic peptide; CV : cardiovascular; eGFR : estimated glomerular filtration rate; HF : heart failure; HFrEF: heart failure with reduced ejection fraction; K + : potassium; RP :
renal profile; NSAIDs : non-steroidal anti-inflammatory drugs; NT-Pro BNP : N-terminal pro B-type natriuretic peptide; SBP : systolic blood pressure; SCr : serum creatinine

26 | HF MTAC Protocol 2nd Edition 2024

 Pharmacotherapy BETA-BLOCKERS SODIUM-GLUCOSE CO-TRANSPORTER MINERALOCORTICOID RECEPTOR
2 INHIBITORS (SGLT2-i) ANTAGONISTS (MRAs)

(Refer Appendix 10 for further information) (Refer Appendix 11 for further information) (Refer Appendix 12 for further information)
Goal - Improve symptoms - Increase survival - Improve symptoms
- Reduce the risk of HF hospitalization - Reduce the risk of HF hospitalization - Reduce the risk of HF hospitalization
- Increase survival - Improve QOL - Increase survival
Target Population For all patients with stable HFrEF Patients with HFrEF (regardless of All symptomatic HFrEF patients in addition
(unless contraindicated) concomitant diabetes mellitus) to other foundational therapies
Monitoring - BP - RP - RP
Parameters/ - Heart rate - Glucose profile - Electrolytes (especially K+)
Investigations - Clinical status (sign & symptoms of - BP - BP
congestion) - Hydration status
- Electrocardiogram
Initial drop in eGFR might be observed
but this should not lead to discontinuation
of SGLT2-i
Initiation/ Titration Refer Appendix 10: Beta Blockers Refer Appendix 11: SGLT2-i Refer Appendix 12: MRAs
Cautions - Severe HF (NYHA class III-IV), try to - Individual risk of ketoacidosis - Significant renal dysfunction (CrCl
relieve congestion and achieve - Glycosuria (as the consequence of its <30ml/min or SCr >221µmol/L)
‘euvolaemia’ before initiate β-blocker. mechanism of action) may predispose to - Significant hyperkalaemia (K+ >5.0)
- Symptomatic bradycardia or fungal genito-urinary infections - Drug interactions
hypotension - Drug interactions (insulin, - K+ supplement/ K+-sparing diuretic
- Bronchospasm, especially among sulphonylureas & other antidiabetic (e.g. amiloride)
patient with known airway disease drugs predisposing to hypoglycaemia) - RAAS blockers
- May potentiate hypoglycaemia and/ or - Concurrent treatment with thiazides & - NSAIDs
mask symptoms in diabetic patient loop diuretics (predisposing to excessive - Trimethoprim or
- Temporary symptomatic deterioration diuresis, symptomatic hypotension & Trimethoprim/Sulfamethoxazole (may
may occur during initiation or up- prerenal renal failure) enhance hyperkalemic effect)
titration phase - Consider temporarily discontinuing - Salt substitutes with a high K+ content
- Renal or hepatic impairment; reduced in settings of reduced oral intake or fluid - Gynecomastia response is related to the
metabolism of drugs losses dose & duration of therapy; reversible
- Use with caution in patient - Consider down-titrate diuretic dose upon following discontinuation of therapy but
concurrently on other rate-control initiation of SGLT2-I may persist (rare)

27 | HF MTAC Protocol 2nd Edition 2024

 agent (e.g. verapamil, diltiazem, - For patient who undergo scheduled
digoxin, ivabradine or amiodarone) surgery, consider temporary
- Should not be stopped abruptly unless discontinuation of therapy at least 3
absolutely necessary due to risk of days prior to surgery; ensure risk factors
‘rebound’ increase in myocardial for ketoacidosis are resolved prior to
ischaemia or arrhythmias reinitiating therapy
- Do not initiate in pt with
eGFR<20ml/min/1.73m2 due to limited
data
Contraindications - 2nd or 3rd degree AV block (in the - Known allergic reaction/other adverse - Acute renal insufficiency, anuria,
absence of a permanent pacemaker) reaction (drug-specific) significant impairment of renal excretory
- Critical limb ischemia - pregnancy/ risk of pregnancy & function
breastfeeding period - Hyperkalaemia
Relative contraindication: Asthma is
- Addison’s disease or other conditions
not necessarily an absolute
associated with hyperkalaemia
contraindication if β-blockers are
indicated, cardio-selective β-blockers
should be used under close medical
supervision by a specialist, with
consideration of risks vs benefits

28 | HF MTAC Protocol 2nd Edition 2024

 Advice to Patients - Explain expected benefits: e.g. - Explain expected benefits: e.g. - Explain expected benefits: e.g. improve
improve symptoms, prevent improve symptoms & QOL, prevent symptoms, prevent worsening of HF
worsening of HF leading to hospital worsening of HF leading to hospital leading to hospital admission, increase
admission, increase survival admission, increase survival survival
- Symptomatic improvement may - Expect improvement in QOL within a - Symptomatic improvement may develop
develop slowly (3-6 months or few weeks to a few months of starting within a few weeks to a few months
longer) treatment - Aware of the potential adverse reactions
- Temporary symptomatic - Should be aware of the risk of of the therapy
deterioration may occur during dehydration, hypotension, - Avoid a diet rich in K+ (i.e. banana,
initiation/ up-titration phase (long hypogylcaemia, ketoacidosis & fungal spinach, seeds & nuts) and NSAIDs
term improves well-being) genito-urinary infections, report to - Avoid salt substitutes high in K+
- Encourage to weigh themselves daily doctor if any
and to consult doctor if they have - To maintain genito-urinary hygiene as
persistent weight gain, consider expected glycosuria
adjust diuretic dose
- Should not stop β-blocker therapy
without consulting their physician

BP : blood pressure; BNP : B-type natriuretic peptide; CV : cardiovascular; eGFR : estimated glomerular filtration rate; HF : heart failure; HFrEF: heart failure with reduced
ejection fraction; K+ : potassium; MRAs : mineralocorticoid receptor antagonists; NYHA : New York Heart Association; NSAIDs : non-steroidal anti-inflammatory drugs; NT-Pro
BNP : N-terminal pro B-type natriuretic peptide; QOL : quality of life; RAAS : renin-angiotensin-aldosterone system; RP : renal profile; SBP : systolic blood pressure; SCr :
serum creatinine; SGLT2-i : Sodium-glucose cotransporter-2 inhibitor; β-blocker : beta blocker

29 | HF MTAC Protocol 2nd Edition 2024

 DIURETICS DIGOXIN IVABRADINE

(Refer Appendix 13 for further information) (Refer Appendix 14 for further information)
Goal Achieve euvolemic state by using the lowest To reduce risk of HF hospitalization - Achieve target HR in HF patient
dose - To reduce risk of HF hospitalization
Target Population Patients with symptoms and signs of - Symptomatic heart failure patient with Patients with stable symptomatic HF and
congestion frequent hospital admissions an EF ≤ 35% SR and resting heart rate
- Rate control in patients with AF ≥70 bpm despite maximally tolerated
dose of β-blocker
Monitoring - BP - RP & Electrolyte (Particularly K+ and - RP
Parameters/ - RP Mg2+) - Liver function
Investigations - Electrolytes - BP - BP
- Hydration status - HR - HR
- Body weight - Electrocardiogram - Electrocardiogram
- TDM Digoxin level
(Regular monitoring of digoxin levels is
not required other than to assess for
toxicity as the levels should not be
used to guide dose adjustment in
chronic therapy)
Initiation/ Titration Refer Appendix 13: Diuretics Regimen - 0.0625 – 0.25mg once daily Refer Appendix 14: Ivabradine
- Higher daily doses (e.g. 0.375 – 0.5mg
daily) are rarely necessary
Cautions - Hypovolemia - Maintain electrolyte balance prior to - Severe HF (NYHA IV)
- Significant hypokalaemia use & throughout therapy (e.g. K+, - Current or recent exacerbation of HF
- Significant renal dysfunction – may be Ca2+, Mg2+). Electrolyte disturbances - Discontinue therapy if resting HR
made worse by diuretic or patient may not can make patient more susceptible to persistently <50bpm
respond to diuretic (especially thiazide digoxin toxicity - Moderate liver dysfunction
diuretic) - Potentially harmful in patient with HCM - Drug interactions
- Symptomatic or severe asymptomatic - Renal impairment or thyroid disease - Heart rate-control agent (due to
hypotension - Narrow therapeutic range potential risk of bradycardia and
- Use with caution in combination with other HF : 0.5 - 0.9 ng/ml long QT as a result of bradycardia)
diuretics AF rate control : 0.8 - 2.0 ng/mL e.g. verapamil, diltiazem, digoxin,
amiodarone

30 | HF MTAC Protocol 2nd Edition 2024

 DIURETICS DIGOXIN IVABRADINE

(Refer Appendix 13 for further information) (Refer Appendix 14 for further information)
Serum concentration of >1.2ng/mL - Strong CYP3A4 inhibitors
may be associated with increased all - Cessation of treatment should be
cause mortality in patients with atrial considered if any unexpected
fibrillation (regardless of heart failure) deterioration in visual function occurs
Contraindications - Complete renal shutdown - Hypersensitivity to Digoxin - Hypersensitivity to Ivabradine
- Uncorrected states of electrolytes depletion - VF - Resting HR <60bpm prior treatment
- Hepatic encephalopathy - 2nd – 3rd heart block - Cardiogenic shock
- Hypovolemia or hypotension - Unstable CV conditions (ACS,
stroke/TIA, severe hypotension)
- Severe hypotension (<90/50mmHg)
- Severe hepatic insufficiency
- AF, SSS, sino-atrial block, 3rd degree
AV-block, pacemaker dependent
- Pregnancy or breastfeeding
Advice to Patient - Take the diuretic tablet before evening to Report ADRs such as vomiting, - Take ivabradine tablet with food
avoid frequent urination until late night diarrhoea, blurred/ yellow vision or - Report any symptoms associated with
- Observe for symptoms of dizzy happens, seek medical attention bradycardia (e.g. syncope, dizziness,
dehydration/hypotension: dizziness, light- as soon as possible lethargy, hypotension)
headedness, fatigue (vague symptoms - Promptly inform doctor/ pharmacist if
may occur in the elderly e.g. confusion, there is visual disturbance after
impaired mobility, falls & urinary treatment (side effect: luminous visual
incontinence) phenomena)
- If experience symptoms of dehydration
(particularly in case of diarrhoea/vomiting,
excessive sweating during hot weather),
report to doctor for dose reduction or
withhold therapy
- Do not adjust the dosage themselves,
unless were taught by the doctor or
pharmacist

31 | HF MTAC Protocol 2nd Edition 2024

 DIURETICS DIGOXIN IVABRADINE

(Refer Appendix 13 for further information) (Refer Appendix 14 for further information)
- Avoid NSAIDs not prescribed by a
physician (may cause diuretic resistance
and renal impairment)
ACS : acute coronary syndrome; ADR : adverse drug reaction; AF : atrial fibrillation; BP : blood pressure; BNP : B-type natriuretic peptide; Ca2+ : calcium; CV : cardiovascular;
eGFR : estimated glomerular filtration rate; EF : ejection fraction; HCM : hypertrophic cardiomyopathy; HF : heart failure; HFrEF: heart failure with reduced ejection fraction; HR
: heart rate; K+ : potassium; MRAs : mineralocorticoid receptor antagonists; Mg2+ : magnesium; NYHA : New York Heart Association; NSAIDs : non-steroidal anti-
inflammatory drugs; NT-Pro BNP : N-terminal pro B-type natriuretic peptide; QOL : quality of life; RAAS : renin-angiotensin-aldosterone system; RP : renal profile; SBP :
systolic blood pressure; SCr : serum creatinine; SGLT2-i : Sodium-glucose cotransporter-2 inhibitor; SR : sinus rhythm; SSS : sick sinus syndrome; TDM : therapeutic drug
monitoring; TIA : transient ischaemic attack; VF : ventricular fibrillation; β-blocker : beta blocker

32 | HF MTAC Protocol 2nd Edition 2024

Appendix 8 : Angiotensin-converting enzyme inhibitor (ACE-i) / Angiotensin
Receptor Blocker (ARB)11-12,14

To improve symptoms, reduce the risk of HF hospitalization, and

Goal
increase survival.
Patients with HF and consider in patients where ARNI
Indication(s) administration is not possible.

Drug Initial Daily Dose(s) Target Dose(s)

ACE-i
Captopril 6.25 mg bd 50 mg tds
Enalapril 2.5 mg od 10-20 mg bd
Lisinopril 2.5-5 mg od 20-40 mg od
Perindopril 2 mg od 8-16 mg od
Ramipril 2.5 mg od 10 mg od
ARB
Candesartan 4-8 mg od 32 mg od
Losartan 25-50 mg od 50-150 mg od
Valsartan 40 mg od 160 mg bd

- Start with a low dose. Patients should not remain on the initial low dose
indefinitely. The dose should be increased gradually to the target dose.
- Consider increasing dose of ACE-i/ARB every 2 weeks until maximum
tolerated or target dose is achieved.

MONITORING

✧ Renal function (Urea/Blood urea nitrogen, Creatinine)

✧ Electrolyte (K+)
✧ Blood pressure
Frequency of monitoring (Renal function)

Initiation and up-titration: Recheck within 2 weeks

With stable dose: Recheck 4 monthly thereafter

33 | HF MTAC Protocol 2nd Edition 2024

MANAGEMENT OF ADVERSE EFFECTS

1) Asymptomatic low blood pressure

✧ Does not usually require any change in therapy.

2) Symptomatic low blood pressure (Dizziness/light-headedness)

✧ Review other medications, reconsider need for any other vasodilators and
reduce dose/stop, if possible.
✧ If no signs or symptoms of congestion, consider reducing diuretic dose, which h
as been found to mitigate the hypotensive effects of ARNI/ACE-i/ARB.
✧ If these measures do not solve problem, consider reducing dose/stop
ARNI/ACE-i/ARB.

Symptomatic hypotension was reported more commonly in patients treated

with Sacubitril/Valsartan as compared to Enalapril.

3) Cough

✧ Cough is common in patient with HF, if have smoking related lung disease.
✧ Cough is also a symptom of pulmonary oedema, which should be excluded when
a new worsening cough develops.
✧ When a troublesome cough does develop (e.g. one stopping the patient from
sleeping) and can be proved to be due to ARNI and ACE-i (e.g. recurs after the
drugs withdrawal and re-challenge), substitution of an ARB is recommended.
4) Hyperkalaemia

✧ An increase in K+ up to ≤ 5.5 mmol/L is acceptable.

✧ If greater rises in K+ despite adjustment of concomitant medications, the dose of
the ARNI/ACE-i/ARB should be halved and blood chemistry rechecked within 1-
2 weeks.
✧ If K+ rises to >5.5 mmol/L or eGFR lowers to <30 mL/min/1.73 m2, the ARNI/AC
E-i/ ARB should be stopped.
5) Blood urea nitrogen

✧ Transient increase in serum creatinine generally occurs within 2 weeks and

stabilize within 2 to 4 weeks.
✧ An increase of serum creatinine up to 30% from baseline is acceptable.
✧ Dose adjustments is not required if the increase in SCr stabilizes at ≤ 30% (or
eGFR reduces <25%).
✧ Additional increase may indicate renal artery stenosis, volume depletion, or
other explanation of kidney dysfunction. Caution /seek specialist advice.

34 | HF MTAC Protocol 2nd Edition 2024

Appendix 9 : Angiotensin Receptor-Neprilysin Inhibitor (ARNI)12,14

● Patients with HF as a replacement for ACE-i/ARB

Indication(s) ● It may be considered in patients with HF in those who are
ACE-i /ARB naive (de novo use)

Dosage Starting Dose Titration Target Dose

Sacubitril/ 24/26 mg bda, or Double the dose at less 97/103 mg bd

Valsartan 49/51 mg bd than 2-week intervals
awith SBP 100-110 mmHg or eGFR < 30mL/min/1.73 m2

Conversion from ACE-i/ARB to ARNI

If previously on ACE-i If previously on ARB

Ensure 36 hours wash out period No washout period required

before ARNI initiation before ARNI initiation

Low dose High dose Low dose High dose

enalapril ≤ 10 enalapril valsartan valsartan
mg/da > 10 mg/da ≤ 160 mg/da > 160 mg/da

Initiate Sacubitril / Valsartan at a dose of :

24/26 mg bd 49/51 mg bd 24/26 mg bd 49/51 mg bd

aor therapeutically equivalent dose of another ACE-i / ARB

Note :
Refer Appendix 8 for monitoring and management of adverse effects with ARNI therapy

35 | HF MTAC Protocol 2nd Edition 2024

Appendix 10 : β-Blockers11-12

To reduce morbidity and mortality in patients with NYHA Class II-IV, of

Goal
both ischaemic and non-ischaemic aetiology, on top of standard therapy.

Indication For heart failure patients unless contraindicated.

Drug Initial Daily Dose(s) Target Dose(s)

Bisoprolol 1.25 mg od 10 mg od
25 mg bd
Carvedilol 3.125 mg bd
(50mg, if > 85kg)
Metoprolol Succinate
12.5-25 mg od 200 mg od
CR/XL**
Nebivolol*** 1.25 mg od 10 mg od
** Currently only metoprolol tartrate is available in Malaysia
*** One study showed reduction in composite endpoint of death or CV hospitalisation with no reduction in
mortality

Titrate to target heart rate: 50-60 bpm

The dose of diuretic may need to be adjusted at β-blocker initiation or up-
titration as patient may experience transient fluid retention.

MONITORING

✧ Heart rate
✧ Blood pressure
✧ Clinical status (symptoms, sign of congestion, body weight)

MANAGEMENT OF ADVERSE EFFECT

1) Asymptomatic low blood pressure

- Does not usually require any change in therapy.

2) Symptomatic low blood pressure (Dizziness/light-headedness)

- Reconsider need for any other vasodilators and reduce dose/stop, if possible.
- If no signs or symptoms of congestion, consider reducing diuretic dose.

36 | HF MTAC Protocol 2nd Edition 2024

 3) Worsening symptoms or signs (e.g. increasing dyspnoea, fatigue, oedema,
weight gain):
- If increasing congestion, increase a dose of diuretic or halve a dose of beta-blocker
(if increasing diuretic dose does not work).

4) Low heart rate:

- If <50 b.p.m. and worsening symptoms, consider withholding beta blocker.

- Review need for other heart rate-slowing drugs (e.g. digoxin, ivabradine,
amiodarone, diltiazem, or verapamil).
- Might need for ECG to exclude heart block.

37 | HF MTAC Protocol 2nd Edition 2024

Appendix 11 : Sodium-Glucose Co-Transporter 2 Inhibitors (SGLT2-i) 12,14,16

Goal To improve symptoms, reduce the risk of HF hospitalization, and

increase survival.
Indication - Patients with HFrEF (irrespective of the presence of type 2 diabetes)
- SGLT2-i can also be beneficial in patients with HFmrEF and HFpEF.

Drug Starting Dose Target Dose

10 mg od 10 mg od
Empagliflozin
Dapagliflozin 10 mg od 10 mg od

Renal exclusion criteria in trials:

EMPEROR-Reduced (Empagliflozin) : eGFR < 20mL/min/1.73 m2
DAPA-HF (Dapagliflozin) : eGFR < 30mL/min/1.73 m2
EMPA-KIDNEY (Empagliflozin) : eGFR < 20mL/min/1.73 m2
DAPA-CKD (Dapagliflozin) : eGFR < 25mL/min/1.73 m2

MONITORING

⮚ Renal function
- Check renal function when starting the therapy and monitor regularly.
- eGFR is known to dip slightly after initiation but the SGLT2 inhibitors appear to
be reno-protective.
⮚ Blood glucose
- Monitor glycaemia regularly, particularly when a patient is diabetic. Consider
modification of other diabetic drugs.
⮚ Risk of euglycemic ketoacidosis
- Identify the risk factors predisposing to ketoacidosis and eliminate them if
possible (e.g. fasting, inadequate fluid intake).
⮚ Risk of mycotic genital infections
- Uro-genital infections may occur during treatment with SGLT2 inhibitors.
Patients should be educated on the signs and symptoms of uro-genital
infections as well as the appropriate preventive measures.
⮚ Fluid balance
- Monitor fluid balance regularly, particularly when a patient is taking diuretics,
old and/or frail. Consider an adjustment of diuretic therapy and fluid intake.

38 | HF MTAC Protocol 2nd Edition 2024

MANAGEMENT OF ADVERSE EFFECT

1) Genito-urinary infections

- Patients should be monitored in the context of symptoms and signs of genito-

urinary fungal infections.
- Infections are usually mild and resolve quickly with appropriate treatment,
discontinuation of the drug is not necessary with most cases. Treatment typically
includes either a single dose of an oral antifungal or application of a topical
antifungal cream for 1 to 3 days.
- Consideration should be given to avoid SGLT2 inhibitors in female patients with
a history of severe, recurrent infections. Preventive strategies are optimized
diabetes management and personal hygiene advice.
2) Hypoglycaemia

- Other diabetic drugs (particularly, insulin and/or sulfonylurea derivates) may

predispose to hypoglycaemia, in this case, the diabetic treatment strategy needs
to be modified.
3) Dehydration, hypotension, and prerenal renal failure

- SGLT2 inhibitors may intensify the diuresis, particularly when accompanied by

Sac/Val and diuretic therapy.
- Fluid balance needs to be monitored. Diuretic doses along with fluid intake
should be balanced in order to avoid dehydration, symptomatic hypotension and
prerenal renal failure.
- Elderly and frail patients are at particular risk of developing these complications.

39 | HF MTAC Protocol 2nd Edition 2024

Appendix 12 : Mineralocorticoid Receptor Antagonist12,14

Goal To improve symptoms, reduce the risk of HF hospitalization, and

increase survival.
Indication Patients with HFrEF.

Drug Starting Dose Target Dose

Spironolactone 12.5 -25 mg oda 50 mg od

Eplerenone 25 mg od 50 mg od

Finerenone 20 mg od 20mg od
aSpironolactone has an optional starting dose of 12.5 mg in patients where renal status or hyperkalaemia warrant
caution
After dose initiation, if K+ increase ≧6.0 mEq/L or worsening renal function, hold until K+ <5.0 mEq/L. Consider
restarting reduced dose after confirming resolution of hyperkalaemia/renal insufficiency for at least 72 hr.

MONITORING

✧ Blood pressure
✧ Renal function
✧ Serum electrolytes: Particularly K+
✧ Volume status
✧ Gynecomastia in men

MANAGEMENT OF ADVERSE EFFECT

1) Hypovolemia/diarrhoea causing dehydration

- Measure blood chemistry.

- Temporarily holding the MRA/diuretic.
2) Worsening Renal Function/ Hyperkalaemia

- If K+ rises above 5.5 mmol/L or creatinine rises to 221 µmol/L /eGFR <30
mL/min/1.73 m2, halve a dose and monitor blood chemistry closely.
- If K+ rises to >6.0 mmol/L or creatinine to >310 µmol/L /eGFR <20 mL/min/1.73
m2, stop MRA immediately and seek specialist advice.
- Potassium levels and renal function should be rechecked approximately at
1week, then 4 weeks after initiating or intensifying MRA, then 3-monthly for the
first year, 4-monthly thereafter.

40 | HF MTAC Protocol 2nd Edition 2024

Appendix 13 : Diuretics11-14,17

Goal - To relieve breathlessness and oedema in patients with symptoms

and signs of congestion.
Indication - Symptoms and signs of congestion, irrespective of LVEF.
- Use in a combination with an ACE-I (or an ARB), a beta-blocker,
and an MRA in patients with HFrEF until signs of congestion have
been relieved (not shown to improve survival).

Drug Initial daily dose Usual daily dose

Loop Diuretic

Furosemide 20-40 mg od / bd 20 – 80 mg

Bumetanide 0.5-1 mg od / bd 0.5 – 2 mg

Thiazides
Hydrochlorothiazide 25 mg od 12.5 – 50 mg

Metolazone 2.5 mg od 2.5 – 10 mg

Loop diuretic approximate oral dose equivalency; Bumetanide 1mg = Furosemide 40mg

DIURETIC DOSING TITRATION

Diuretic Dose Titration

- Thiazide diuretics may be preferred for mild fluid retention, particularly in patient with
concurrent hypertension. Thiazides, however, only possess mild diuresis effect.
- A loop diuretic is often needed in majority patients with chronic HF to sustain
euvolemia and clinical stability.
⮚ Initial dose depends on multiple factors including kidney function and prior
exposure to diuretic therapy.
⮚ Titrate dose to relief of congestion over days to weeks.
⮚ In some instances, it may be necessary to reduce diuretic dosing in the setting
of increasing doses of ARNI/ACE-i/ARB and/or initiation of SGLT2-i.
⮚ The goal is to use of the lowest dose that permits effective maintenance of
euvolemia.
- Combination of metolazone and loop diuretics may be considered in patients with
refractory edema and advanced renal impairment. (Caution: higher risk of
electrolyte imbalances and increased mortality).

* In severe congestive HF and ADHF, oral diuretic therapy may be ineffective.

41 | HF MTAC Protocol 2nd Edition 2024

PATIENT’S GUIDE TO DIURETIC DOSE ADJUSTMENT
Patients should be educated in ‘dry weight’ management and advised to record
their daily weight. Selected patients should be educated to self-adjust their diuretic
(furosemide) dose together with restriction of their fluid intake until regain their “dry
weight”.

Furosemide dose adjustment if body weight increases

1. If there is a consistent increase in weight of > 2kg in 3 days, selected patient can
be taught to self-adjust the dose of furosemide.
2. Once dry weight is achieved, change furosemide dose to baseline.

3. If there is no response to the increased furosemide dose after 3 days (or earlier if c
ondition deteriorates), seek medical attention immediately.

Diuretic Dose Dose frequency Sliding scale adjustment

Furosemide 20 mg AM daily Extra 20 mg PM
Furosemide 40 mg AM daily Extra 40 mg PM
Extra 40 mg PM
Furosemide 80 mg AM daily
If needed ↑ to extra 80 mg PM
Furosemide 20 mg Twice daily Extra 20 mg AM
Furosemide 40 mg Twice daily Extra 40 mg AM
Extra 40 mg at noon
Furosemide 80 mg Twice daily
If needed ↑ to extra 80 mg noon
Cut back to usual diuretic dose as weight, swelling, and symptoms permit
*Dose may need to be decreased if there is fluid loss (e.g. due to diarrhoea/vomiting,
excessive sweating).
MONITORING

⮚ Renal function
⮚ Fluid status
- Fluid input and output
⮚ Serum electrolyte
- Sodium, potassium, magnesium
⮚ Blood pressure
⮚ Body weight
⮚ Drug interactions
- Combination with other diuretic - risk of hypovolaemia, hypotension,
hypokalaemia, and renal impairment.
- NSAIDs - may attenuate effect of diuretic.

42 | HF MTAC Protocol 2nd Edition 2024

MANAGEMENT OF ADVERSE EFFECT

1) Asymptomatic low blood pressure

- Dose may be reduced if no symptoms or signs of congestion.
2) Symptomatic hypotension:
- Dizziness/light-headedness; reduce dose if no signs/symptoms of congestion.
- Review medications and reconsider need for nitrates, CCBs and other vasodilators.

3) Hypokalaemia/hypomagnesaemia:
- Increase an ACE-I/ARB dose.
- Add an MRA, K+ supplements; magnesium supplements.
4) Hyponatraemia (<135 mmol/L):
If volume depleted:
- Stop thiazide
- Reduce dose/stop loop diuretics if possible
If volume overloaded: (seek specialist advice- patient might need IV diuretic)
- Fluid restriction
- Consider increasing dose of loop diuretic
- Consider AVP antagonist (e.g. tolvaptan if available)
5) Hypovolaemia / dehydration
Assess volume status; consider a diuretic dosage reduction.
6) Hyperuricaemia / gout
- For gouty flares use colchicine for pain relief.
- Avoid NSAIDs.
- Consider allopurinol prophylaxis (not initiated during acute exacerbation).
7) Insufficient diuretic response/diuretic resistance

- Check adherence and fluid/salt intake.

- Increase dose of diuretic / consider switching from furosemide to bumetanide.
- Add an MRA/increase dose of an MRA.
- Combine loop diuretic and thiazide/metolazone.
- Administer loop diuretic twice (or more times) daily or on empty stomach.
5) Worsening of renal function
- Check for hypovolaemia/dehydration.
- If using concomitant loop and thiazide diuretic, stop thiazide diuretic.
- Avoid nephrotoxic agents, e.g. NSAIDs, trimethoprim.
- Withhold an MRA.
- Consider reducing a dose of ACE-I/ARB.

43 | HF MTAC Protocol 2nd Edition 2024

Appendix 14 : Ivabradine11-14,18

Goal To reduce HF hospitalizations and cardiovascular death.

Indication - Stable symptomatic HF patient with LVEF ≤ 35%, who are receiving
GDMT, including a beta blocker at maximum tolerated dose.
- Sinus rhythm with a heart rate of ≥ 70 bpm at rest.

Drug Starting Dose Target Dose

Ivabradine 2.5 – 5 mg bd 7.5 mg bd

Titrate to target heart rate: 50-60 bpm

If Channel inhibitor dose initiation and titration

IVABRADINE

Re-assess that beta blockers are adjusted to

maximally tolerated doses and/or target doses
Verify patient is in sinus rhythm
2. Ensure, bisoprolol dose adjusted to maximum
tolerated dose / target dose
Starting dose

Age ≥ 75 years, Age < 75 years,

2.5 mg bd with food 5 mg bd with food

After initiation, reassess heart rate within 2-4 weeks

Heart rate < 50 bpm

Heart rate:
or Heart rate > 60 bpm
50-60 bpm
Symptoms of bradycardia

Reduce dose by 2.5 mg bd Maintain current d Increase by 2.5 mg bd

or discontinue if already at ose and monitor until reach maximum
2.5 mg bd heart rate dose 7.5 mg bd

44 | HF MTAC Protocol 2nd Edition 2024

MONITORING

⮚ Heart rate (prior to initiation, increasing or after decreasing dose)

⮚ Blood pressure
⮚ Cardiac rhythm
⮚ Liver profile
⮚ Drug interactions
- negative chronotropic drugs (due to potential risk of bradycardia and long QT
as a result of bradycardia) e.g. verapamil, diltiazem, digoxin, amiodarone
- Strong CYP3A4 inhibitors (e.g. antifungal azoles, macrolide antibiotic, HIV
protease inhibitors)

MANAGEMENT OF ADVERSE EFFECT

1) Resting heart rate decreases persistently below 50 bpm or if symptoms of

bradycardia occur:

- Review needs for other heart rate-slowing drugs or drugs interfering with
metabolism of ivabradine.
- Arrange ECG to exclude other than sinus bradycardia rhythm disturbances.
- Consider screening for secondary causes of bradyarrhythmia (e.g. thyroid
dysfunction).
- Consider reduce/withhold ivabradine.
2) Develops persistent/continuous AF during therapy

Discontinue ivabradine.
3) Visual disturbances

- Visual phenomena are usually transient and disappear during the first few
months of ivabradine treatment and are not associated with serious retinal
dysfunction. Consider discontinue if symptoms result in patient’s discomfort.
- Cessation of treatment should be considered if any unexpected deterioration in
visual function occurs.

45 | HF MTAC Protocol 2nd Edition 2024

Appendix 15 : Salt Content in Common Malaysian Foods11

Daily Reference Intake (DRI) for salt: 5 g per day (1 teaspoon)

- -

- -

- -

- -

- -

- -

- -

- -

- -

- -

- -

- -

- -

- -

46 | HF MTAC Protocol 2nd Edition 2024

 - - - -

- - - -

- - - -

- - - -

- - - -

- - - -

- - - -

- - - -

- - - -

- - - -

- - - -

- - - -

- - - -

- - - -

- - - -

- - - -

- - - -

- - - -

- - - -

- - - -

Source: Clinical Practice Guidelines: Management of Heart Failure 2023 5th edition

47 | HF MTAC Protocol 2nd Edition 2024

48 | HF MTAC Protocol 2nd Edition 2024