p.44 抽出テキスト

May 3, 2022 Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 e938

CLINICAL STATEMENTS AND GUIDELINES

There are no direct data showing that use of lower doses of HFrEF medications among patients, where higher target doses could be tolerated, would produce the same or simi- lar degree of clinical benefit. In trials that have evaluated dose response for outcomes, composite event rates were lower with target doses compared with lower dose.16–18

Table 14.  Drugs Commonly Used for HFrEF (Stage C HF)

Drug Initial Daily Dose(s) Target Doses(s) Mean Doses Achieved in Clinical Trials References ACEi Captopril 6.25 mg 3 times daily 50 mg 3 times daily 122.7 mg total daily 19 Enalapril 2.5 mg twice daily 10–20 mg twice daily 16.6 mg total daily 3 Fosinopril 5–10 mg once daily 40 mg once daily NA ... Lisinopril 2.5–5 mg once daily 20–40 mg once daily 32.5–35.0 mg total daily 17 Perindopril 2 mg once daily 8–16 mg once daily NA ... Quinapril 5 mg twice daily 20 mg twice daily NA ... Ramipril 1.25–2.5 mg once daily 10 mg once daily NA ... Trandolapril 1 mg once daily 4 mg once daily NA ... ARB Candesartan 4–8 mg once daily 32 mg once daily 24 mg total daily 20 Losartan 25–50 mg once daily 50–150 mg once daily 129 mg total daily 18 Valsartan 20–40 mg once daily 160 mg twice daily 254 mg total daily 21 ARNi Sacubitril-valsartan 49 mg sacubitril and 51 mg valsartan twice daily (therapy may be initiated at 24 mg sacubitril and 26 mg valsartan twice daily) 97 mg sacubitril and 103 mg valsartan twice daily 182 mg sacubitril and 193 mg valsartan total daily

22 Beta blockers

Bisoprolol 1.25 mg once daily 10 mg once daily 8.6 mg total daily 1 Carvedilol 3.125 mg twice daily 25–50 mg twice daily 37 mg total daily 23 Carvedilol CR 10 mg once daily 80 mg once daily NA ... Metoprolol succinate extended release (metoprolol CR/XL) 12.5–25 mg once daily 200 mg once daily 159 mg total daily 11 Mineralocorticoid receptor antagonists Spironolactone 12.5–25 mg once daily 25–50 mg once daily 26 mg total daily 6 Eplerenone 25 mg once daily 50 mg once daily 42.6 mg total daily 13 SGLT2i Dapagliflozin 10 mg once daily 10 mg once daily 9.8 mg total daily 8 Empagliflozin 10 mg once daily 10 mg once daily NR 9 Isosorbide dinitrate and hydralazine Fixed dose combination 20 mg isosorbide dinitrate and 37.5 mg hydralazine 3 times daily 40 mg isosorbide dinitrate and 75 mg hydralazine 3 times daily 90 mg isosorbide dinitrate and ∼175 mg hydralazine total daily

10 Isosorbide dinitrate and hydrala- zine

20–30 mg isosorbide dinitrate and 25–50 mg hydralazine 3–4 times daily 120 mg isosorbide dinitrate total daily in divided doses and 300 mg hydralazine total daily in divided doses NA 24

If Channel inhibitor Ivabradine 5 mg twice daily 7.5 mg twice daily 12.8 total daily 25–27 Soluble guanylate cyclase stimulator Vericiguat 2.5 mg once daily 10 mg once daily 9.2 mg total daily 28 Cardiac glycoside Digoxin 0.125–0.25 mg daily (modified according to monogram) Individualized variable dose to achieve serum digoxin concentration 0.5–<0.9 ng/mL NA 29,30 ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; CR, controlled release; CR/XL, controlled release/extended release; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; NA, not applicable; NR, not reported; and SGLT2i, sodium glucose cotransporter 2 inhibitor.

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