with New York Heart Association (NYHA) class II to IV stable chronic heart failure with systolic dysfunction and Target dose: 10 daily (or 5mg twice daily post MI, switch to once daily dosing once optimum tolerated dose is reached)

An ARB licensed for heart failure (candesartan is licensed for use in combination with ACE inhibitors, losartan is not) Aim for the target dose but the use of maximum tolerated dose is likely to be more beneficial than no ACE inhibitor. If symptoms persist despite optimal first-line therapy, seek specialist advice and consider adding: Monitor U&E, creatinine etc. as described in 2.5.5 Drugs affecting the renin-angiotensin system. NICE considers that an increase in creatinine of up to 50% of baseline or a maximum of 200 micromol/L is acceptable. Cardiac resynchronisation therapy for patient with a wide QRS complex (pacing with or without a defibrillator)Aldosterone antagonists (spironolactone or eplerenone) licensed for heart failure (especially in moderate to severe heart failure or MI in past month)

Diuretic therapy is likely to be required at all stages in treatment, to control symptoms of congestion and fluid retention For more information, see dapagliflozin and empagliflozin under SGLT2 inhibitors (6.1.2 Antidiabetic drugs) Maximum dose of carvedilol in severe heart failure is 25mg twice daily. In mild to moderate heart failure the maximum dose in patients weighing under 85kg is 25mg twice daily, otherwise it is 50mg twice daily. If patient is already taking a thiazide diuretic for hypertension review treatment (combination can cause profound diuresis)