Heart Failure - Chronic Drug Summary

Last updated: 29 April 2025

Content on this page:

ACE Inhibitors

Content on this page:

ACE Inhibitors

ACE Inhibitors


Drug Dosage Remarks
Benazepril Initial dose: 2.5 mg PO 24 hourly
Adjust dose gradually according to response
Max dose: 20 mg/day		 Adverse Reactions
  • CV effects (hypotension, palpitations); CNS effects (fatigue, headache, dizziness); GI effect (taste disturbances); Respiratory effects (persistent dry cough, upper respiratory tract symptoms); Dermatologic effects (skin rashes, erythema multiforme, toxic epidermal necrolysis, pruritus, angioedema, photosensitivity reaction); Renal effect (renal impairment); Other effects (electrolyte disturbances, eg hyperkalemia, hyponatremia; blood disorders)
Special Instructions
  • Patients with HF and those who may be salt or water depleted (taking diuretic or on dialysis) may experience hypotension during initial stages of ACE inhibitor therapy
    • Start treatment only under close medical supervision; in these patients use a low dose and have the patient in a supine position
  • Start with low dose and if lower doses have been tolerated, gradually increase dose every 2 weeks until maximum tolerated dose is achieved
  • Avoid in patients with aortic stenosis, mitral stenosis, outflow tract obstruction, renovascular disease (eg renal artery stenosis, severe renal insufficiency) and hereditary or idiopathic angioedema
  • Should not be given to patients if they have experienced life-threatening adverse reactions (angioedema or renal failure) with or without previous exposure to the drug, hypotensive patients who are at immediate risk of cardiogenic shock
  • Check BP, renal function and electrolytes 1-2 weeks after each dose increment, at 3 months then every 6 months
    • More frequent monitoring is necessary in patients with previous or existing renal dysfunction
  • NSAIDs should be avoided since they can block the beneficial effects and increase adverse effects of ACE inhibitors and may synergistically compromise renal function
Captopril Initial dose: 6.25-12.5 mg PO 8-12 hourly Adjust dose gradually according to response
Maintenance dose: 25 mg PO 8-12 hourly or 50 mg PO 8 hourly
Max dose: 150 mg/day
Cilazapril Initial dose: 0.5 mg PO 24 hourly
Maintenance dose: 1-2.5 mg PO 24 hourly
Max dose: 5 mg/day
Enalapril Initial dose: 2.5 mg PO 24 hourly
Maintenance dose: 20 mg PO 24 hourly or divided 12 hourly
Max dose: 40 mg/day
Fosinopril Initial dose: 10 mg PO 24 hourly
Adjust dose gradually according to response
Max dose: 40 mg/day
Imidapril Initial dose: 2.5-10 mg PO 24 hourly Adjust dose gradually according to patient’s age and response
Lisinopril Initial dose: 2.5 mg PO 24 hourly
Maintenance dose: 5-20 mg PO 24 hourly
Max dose: 40 mg/day
Perindopril1 Initial dose: 2-2.5 mg PO 24 hourly Maintenance dose: 4-5 mg PO 24 hourly
Quinapril Initial dose: 5 mg PO 12-24 hourly Maintenance dose: 10-40 mg/day PO divided 12 hourly
Max dose: 40 mg/day
Ramipril Initial dose: 1.25 mg PO 24 hourly
Adjust dose gradually according to response
Doses ≥2.5 mg/day may be given 24 hourly or divided 12 hourly
Max dose: 10 mg/day
Trandolapril Initial dose: : 1 mg PO 24 hourly
Adjust dose gradually according to response
Max dose: 4 mg/day
1Combination with Bisoprolol is available. Please see the latest MIMS for specific formulations and prescribing information.

Adrenergic Agonist


Drug Dosage Remarks
Dopamine Initial dose: 2-5 mcg/kg/min IV infusion Gradually increase by 5-10 mcg/kg/min increments
Max dose: 20-50 mcg/kg/min
 Adverse Reactions
  • CV effects (ectopic beats, tachycardia, palpitations, anginal pain, hypotension, vasoconstriction); Other effects (nausea/vomiting, headache, dyspnea)
  • Less common: CV effects (bradycardia, cardiac conduction abnormalities, hypertension may occur if overdosage); Other effects (piloerection, azotemia)
Special Instructions
  • Hypovolemia should be corrected prior to treatment
  • Avoid in patients with pheochromocytoma, hyperthyroidism and uncorrected tachyarrhythmias or ventricular fibrillation
  • Use with caution and in low dose in patients with shock secondary to MI, patients with history of peripheral vascular disease (PVD) who are at increased risk of ischemia of the extremities
  • Use with caution in patients with hypersensitivity to sodium metabisulfite
  • When discontinuing, it may be necessary to gradually decrease the dose while expanding blood volume with IV fluids to prevent hypotension

Angiotensin II Antagonists



Drug Dosage Remarks
Candesartan Initial dose: 4 mg PO 24 hourly
Increase dose at intervals of 2 weeks to reach the target dose
Max dose: 32 mg/day 		Adverse Reactions
  • Usually mild and transient: CNS effects (dizziness, headache); CV effect (dose-related orthostatic hypotension which may occur particularly in patients with volume depletion)

Special Instruction

  • Patients with volume depletion (eg high-dose diuretic therapy) may experience hypotension and should be started on low dose
  • Increase dose every 1-2 weeks until maximum tolerated or target dose is achieved
  • Use with caution in patients with renal artery stenosis, renal impairment or hepatic impairment, aortic stenosis, mitral stenosis, obstructive hypertrophic cardiomyopathy, primary hyperaldosteronism
  • Contraindicated in patients with severe renal or hepatic dysfunction and cholestasis
  • Check BP, renal function and electrolytes 1-2 weeks after each dose increment, at 3 months then every 6 months
    • More frequent monitoring is necessary in patients with previous or existing renal dysfunction
Losartan Initial dose: 12.5 mg PO 24 hourly Titrated at weekly intervals to 12.5 mg, 25 mg, 50 mg, 100 mg PO 24 hourly up to Max dose: 150 mg/day
Valsartan Initial dose: 40 mg PO 12 hourly
May increase to 80-160 mg PO 12 hourly at least at 2-week interval
Max dose: 320 mg/day
Angiotensin Receptor-Neprilysin Inhibitor (ARNI)
Sacubitril/Valsartan 100 mg PO 12 hourly doubled up to 200 mg PO 12 hourly every 2-4 weeks Patient not on ACE inhibitor or ARB
Starting dose: 50 mg PO 12 hourly 

Adverse Reactions

  • GI effects (diarrhea, nausea, gastritis); CNS effects (dizziness, headache, syncope, asthenia); Metabolic effects (hyper- or hypokalemia, hypoglycemia); Other effects (hypotension, renal impairment, anemia, cough, fatigue)

Special Instructions

  • Not to be administered until 36 hours after last dose of ACE inhibitor
  • Temporary down-titration/discontinue administration in case of symptomatic hypotension, hyperkalemia or renal dysfunction
  • Treatment should not be initiated in patient with serum K level >5.4 mmol/L or SBP <100 mmHg; not recommended for end-stage renal disease
  • Starting dose of 50 mg 12 hourly is recommended for patient with eGFR <30 mL/min/1.73 m2 (use with caution) or moderate hepatic impairment (Child-Pugh Class B) or if patient is taking Enalapril ≤10 mg/day or equivalent or Valsartan ≤160 mg/day or equivalent
  • Starting dose of 100 mg 12 hourly is recommended for patient taking Enalapril >10 mg/day or equivalent or Valsartan >160 mg/day or equivalent
  • Caution is required in patient with renal artery stenosis and monitoring of renal function is recommended; caution when initiating in patient with NYHA Class IV
  • Contraindicated in patients with known history of angioedema related to previous ACE inhibitor or ARB therapy, hereditary or idiopathic angioedema, concomitant use with ACE inhibitors or ARBs, Aliskiren-containing medicinal products in patients with DM or renal impairment, severe hepatic impairment, biliary cirrhosis and cholestasis
  • Check BP, renal function and electrolytes after initiation and during dose titration

Antidiabetic Agents



Drug Dosage Remarks
Sodium-Glucose Linked Transporter/Co-transporter 2 (SGLT2) Inhibitors
Dapagliflozin1 10 mg PO 24 hourly
Adverse Reactions
  • GU effects (polyuria, dysuria, vulvovaginitis, balanitis, increased susceptibility to infections); Renal effect (acute kidney injury); Hematologic effect (increased hematocrit); GI effects (nausea, constipation); CV effects (hypotension, decreased blood volume); Other effects (dyslipidemia, increased creatinine and urea levels, hypoglycemia, rash, hyperhidrosis, back pain, euglycemic diabetic ketoacidosis)
  • Electrolyte disturbances (hyperphosphatemia, hypermagnesemia, hyperkalemia)

Special Instruction

  • Monitor kidney function prior to starting therapy and assess periodically during therapy
  • Should not be given in patients with severe renal impairment
  • Though current evidence suggests that CV and renal benefits appear to be maintained even at eGFR levels as low as 30 mL/min/1.73 m², physicians need to recognize that at a level of CKD stage 3b and lower, the glucose-lowering efficacy of SGLT2 inhibitors is weak
    • Ensure Dapagliflozin eGFR is ≥25 mL/min/1.73 m² prior to treatment initiation; no lower bound cutoff for Empagliflozin
  • Use with caution in patients taking diuretics, NSAIDs and those with decreased blood volume and congestive heart failure
  • May need to lower doses of insulin, sulfonylurea, insulin secretagogues when used concomitantly with SGLT2 inhibitors
  • Consider withholding SGLT2 inhibitors in events that may precipitate diabetic ketoacidosis, eg intercurrent illness, surgery (elective or emergency), trauma, severe carbohydrate restriction
  • SGLT2 inhibitors are generally safe for diabetic patients during Ramadan but should be discontinued in select patients whose risk for adverse effects might be increased
Empagliflozin 10 mg PO 24 hourly
Sotagliflozin 200 mg PO 24 hourly
May titrate to 400 mg PO 24 hourly as tolerated

Adverse Reactions

  • GU effects (urinary tract infection, genital mycotic infection); Other effects (volume depletion, diarrhea, hypoglycemia, dizziness)

Special Instructions

  • Correct volume status before initiating treatment; in patients with decompensated HF, start dosing when they are hemodynamically stable
  • Ensure eGFR is ≥25 mL/min/1.73 m² prior to treatment initiation
  • Withhold treatment at least 3 days, if possible, before major surgery or procedures associated with prolonged fasting
  • Use with caution in patients with type 1 DM and diabetic ketoacidosis, volume depletion, urosepsis, pyelonephritis, Fournier’s gangrene, genital mycotic infections
  • May need to lower dose of insulin or insulin secretagogue when used concomitantly with Sotagliflozin
1Combination with Metformin is available. Please see the latest MIMS for specific formulations and prescribing information.

Calcium Antagonists



Drug Dosage Remarks
Dihydropyridines Adverse Reactions
  • CV effects (depression of cardiac function, hypotension, worsening HF, edema, flushing, tachycardia, palpitations, ischemic chest pain); GI effects (nausea, dyspepsia, dry mouth, constipation, abdominal pain, abnormal LFTs, gingival hyperplasia); CNS effects (headache, dizziness, tremor, insomnia, paresthesia); Hematologic effect (thrombocytopenia); Dermatologic effect (rashes)
  • Short-acting dihydropyridine agents should be avoided because they have the potential to enhance risk of adverse cardiac events
Special Instructions
  • Contraindicated in patients with overt decompensated HF, though vasoselective dihydropyridines (eg Amlodipine, Felodipine) are tolerated in patients with a decreased LVEF
  • Avoid in patients with cardiogenic shock, recent MI or acute unstable angina, severe aortic stenosis
  • Use with caution in patients with acute cerebral infarction or hemorrhage, pheochromocytoma, hepatic impairment or decreased hepatic blood flow, portal hypertension, renal impairment and CHF
  • Sudden withdrawal may exacerbate angina
Amlodipine Initial dose:  5 mg PO 24 hourly
Max dose: 10 mg/day
Benidipine Initial dose:  2-4 mg PO 24 hourly
Max dose: 8 mg/day
Felodipine Initial dose:  5 mg PO 24 hourly 
Max dose: 10 mg/day
Isradipine Initial dose: 1.25 mg PO 12 hourly or
2.5 mg PO 24 hourly
Nicardipine Initial dose: 20 mg PO 8 hourly
May increase at intervals of at least 3 days until required effect is achieved
Maintenance dose: 30 mg PO 8 hourly or
60-120 mg/day PO in divided doses
Nisoldipine Initial dose: 10 mg PO 24 hourly
Maintenance dose: 20-40 mg PO 24 hourly

Cardiac Glycosides



Drug Dosage Remarks
Digoxin 62.5-250 mcg PO 24 hourly
Elderly, patients with impaired renal function or low lean body mass:
62.5 mcg/day PO or
125 mcg PO every other day		 Adverse Reactions
  • Side effects usually due to Digoxin toxicity or overdosage & Digoxin is usually well-tolerated at the recommended doses for CHF
  • Digoxin toxicity: GI effects (nausea/vomiting, anorexia, diarrhea, abdominal pain) are usually the first signs of Digoxin toxicity; Other signs of toxicity: CNS effects (headache, fatigue, facial pain, weakness, dizziness, mental confusion); Visual disturbances (blurred vision, color disturbances); Toxic doses may cause serious CV effects (aggravation of HF, arrhythmias, conduction disturbances)
  • Hypokalemia can predispose a person to Digoxin toxicity
Special Instructions
  • Loading doses are not necessary in CHF patients
    • Dosage is individualized according to age, lean body weight and renal status; adjust dose based on toxicity, efficacy, and blood levels
  • Avoid in patients with obstructive cardiomyopathy unless there is severe HF, in patients with Wolff-Parkinson-White (WPW) syndrome or evidence of accessory pathway
  • Contraindicated in patients with ventricular tachycardia, intermittent complete heart block or second-degree AV block
  • Use with caution in partial heart block, sinus node disorders, acute myocarditis, acute MI, advanced HF, severe pulmonary disease, thyroid dysfunction, in patients undergoing electrocardioversion (withhold Digoxin for 24 hours prior to procedure) and with other drugs that can depress the sinus or AV nodal function (eg Amiodarone or beta-blocker)
  • Hypokalemia, hypercalcemia, hypomagnesemia, hypoxia and hypothyroidism may affect the sensitivity to Digoxin
  • Monitoring of Digoxin levels is only necessary if there is suspected toxicity
Metildigoxin (Methyl digoxin) 100-600 mcg PO 24 hourly

Diuretics



Drug Dosage Remarks
Aldosterone Antagonists
Eplerenone Initial dose: 25 mg PO 24 hourly
May increase dose to 50 mg PO 24 hourly within 4 weeks
Max dose: 50 mg/day		 Adverse Reactions
  • CNS effects (headache, dizziness, drowsiness, ataxia, mental confusion); GI effects (cramps, diarrhea, abdominal pain, elevated liver enzymes); CV effect (angina); Endocrine and metabolic effects (gynecomastia, hirsutism, menstrual irregularities, impotence, mild acidosis, hyponatremia, hyperkalemia, increased uric acid, and transient increases in BUN); Respiratory effect (cough); Dermatologic effects (rash, angioneurotic edema)
Special Instructions
  • Prior to initiation of therapy, verify that eGFR ≥30 mL/min/1.73 m2, creatinine ≤2.5 mg/dL (men) or ≤2 mg/dL (women) and serum K ≤5 mEq/L
  • Closely monitor serum K and renal function 3 days after initiating therapy, at 1 week after initiation/titration, at least monthly for the first 3 months of treatment, then every 3 months thereafter
  • Avoid in patients with hyperkalemia, severe renal impairment or Addison’s disease
  • Use with caution in patients at increased risk of developing hyperkalemia (eg DM, elderly, patients with renal or hepatic impairment)
Spironolactone1 Initial dose:
12.5-25 mg PO 24 hourly
If after 1 month patient is still symptomatic but normokalemic, increase dose to 50 mg PO 24 hourly
Carbonic Anhydrase Inhibitor
Acetazolamide 250-375 mg PO 24 hourly in the morning

Adverse Reactions

  • CNS effects (paresthesia, drowsiness, confusion); Other effects (loss of appetite, hearing dysfunction, taste alteration, GI disturbances, polyuria, acidosis, transient myopia)

Special Instructions

  • Avoid in patients with depressed Na and/or K blood serum levels, marked kidney or liver disease, hyperchloremic acidosis, cirrhosis
  • Use with caution in patients with pulmonary obstruction or emphysema; rapid ascent to high altitude
Loop Diuretics
Bumetanide Initial dose: 0.5-1 mg PO 24 hourly
Give 2nd dose 6-8 hours later if necessary
High doses may be given 8-12 hourly
Max dose: 10 mg/day		 Adverse Reactions
  • Endocrine and metabolic effects (hypomagnesemia, hyponatremia, hypokalemia and hypochloremic alkalosis especially after large doses or prolonged administration, hyperglycemia, glycosuria, hyperuricemia and may precipitate gout)
  • Signs of electrolyte imbalance: Headache, hypotension, muscle cramps, dry mouth, drowsiness, thirst, weakness
Special Instructions
  • Avoid in patients with anuria or in renal insufficiency caused by nephrotoxic or hepatotoxic drugs or caused by hepatic coma
  • Contraindicated in patients with severe electrolyte depletion, hypersensitivity to sulfonamides and Furosemide, Addison’s disease
  • Use with caution in patients with existing or at a risk of fluid and electrolyte imbalances, prostatic hyperplasia, impairment of micturition and gout
  • Patients with hepatic cirrhosis are more likely to develop hypokalemia and patients with severe HF are more likely to suffer hyponatremia
  • Monitor patient’s BP, renal function and electrolytes after initiation and during dose titration
Furosemide
(Frusemide)2		 Initial dose: 20-80 mg PO 12-24 hourly
Max dose: 600 mg/day
Torasemide
(Torsemide)		 10-20 mg PO 24 hourly
Max dose: 200 mg/day
Potassium-Sparing Diuretics
Amiloride3 Patient on ACE inhibitor
Initial dose: 2.5 mg PO 24 hourly
Max dose: 20 mg/day
Patient not on ACE inhibitor
Initial dose: 5-10 mg PO 24 hourly
Max dose: 20 mg/day 		Adverse Reactions
  • Endocrine and metabolic effects (hyperkalemia especially in the elderly, patients with DM and patients with impaired renal function, hyponatremia has occurred in patients receiving combination diuretic therapy); GI effects (nausea/vomiting, abdominal pain, diarrhea, constipation, thirst); CNS effects (headache, dizziness, weakness, paresthesia); CV effect (orthostatic hypotension); Dermatologic effects (rash, pruritus)
Special Instructions
  • Use only if hypokalemia persists after the start of ACE inhibitors and other diuretics
  • Avoid in patients with hyperkalemia or severe renal impairment
  • Use with caution in patients at increased risk of developing hyperkalemia (eg DM, elderly, patients with renal or hepatic impairment)
  • Use 1 week low dose and check serum K and creatinine after 5-7 days of therapy and titrate dose as required
    • Continue to recheck serum K and creatinine every 5-7 days until K values are stable
    • Monitor serum electrolytes regularly
  • Discontinue for at least 3 days before glucose tolerance tests are done
Triamterene Patient on ACE inhibitor
Initial dose: 25 mg PO 24 hourly
Max dose: 100 mg/day
Patient not on ACE inhibitor
Initial dose: 100 mg PO 12 hourly
Max dose: 300 mg/day
Thiazides & Related Diuretics
Bendroflumethiazide Initial dose:
5-10 mg PO 24 hourly or on alternate days
Maintenance dose:
5-30 mg PO weekly in divided doses
Max dose: 20 mg/day		 Adverse Reactions
  • CV effects (postural hypotension, venous thrombosis); Endocrine and metabolic effects (hyperuricemia and may precipitate gout in some patients, hypochloremic alkalosis, hyponatremia, hypokalemia, hyponatremia, hypomagnesemia, hyperglycemia and glucosuria in DM or other susceptible patients, altered lipid concentrations); GI effects (GI irritation, nausea/vomiting, constipation, anorexia, diarrhea, pancreatitis, intrahepatic cholestasis); CNS effects (headache, dizziness, lethargy, syncope, vertigo, paresthesia); Dermatologic effects (hypersensitivity reactions, photosensitivity); GU effect (impotence)
  • Signs of electrolyte imbalances: Headache, muscle cramps, dry mouth, hypotension, thirst, weakness, drowsiness
Special Instructions
  • Do not use thiazides if GFR <30 mL/min unless used synergistically with loop diuretics
  • Avoid in patients with severe hepatic impairment if encephalopathy may be precipitated, in patients with severe renal impairment or anuria, in patients with preexisting hypercalcemia, symptomatic hyperuricemia, sulfonamide allergy, Addison’s disease and refractory hypokalemia, hyponatremia
  • Use with caution in patients with existing or at risk of fluid and electrolyte imbalances (eg elderly), patients with hepatic cirrhosis are more likely to develop hypokalemia and patients with severe HF are more likely to suffer hyponatremia
  • Use with caution in patients with hepatic and renal impairment, porphyria, hyperlipidemia and extrasystole
  • May exacerbate SLE and aggravate DM and gout
  • Monitor patient for signs of fluid and electrolyte imbalance
Chlortalidone
(Chlorthalidone) 		Initial dose: 25-50 mg PO 24 hourly
May increase to 100-200 mg PO 24 hourly in severe cases
Maintenance dose:
25-50 mg PO 24 hourly or on alternate days
Max dose: 200 mg/day
Cyclopenthiazide Initial dose: 0.25-0.5 mg PO 24 hourly
Reduce to lowest effective dose for maintenance
Max dose: 1 mg/day
Hydrochlorothiazide4
(Dihydrochlorothiazide)		 Initial dose: 25 mg PO 24 hourly
Maintenance dose:
25-100 mg PO 24 hourly
Max dose: 200 mg/day
Indapamide Initial dose: 1.5-2.5 mg PO 24 hourly
May increase to 5 mg PO 24 hourly after 1 week if necessary
Max dose: 5 mg/day
Metolazone Initial dose: 2.5 mg PO 24 hourly
May increase to 20 mg PO 24 hourly
Max dose: 80 mg/day
Vasopressin Antagonist
Tolvaptan Usual dose: 15 mg PO 24 hourly
May increase to 30 mg PO 24 hourly after at least 24 hours
For patients with serum Na <125 mEq/L or for whom rapid volume decrease is considered inappropriate:
Start with 7.5 mg PO 24 hourly
Max dose: 60 mg/day
Max duration of therapy: 30 days

Adverse Reactions

  • GI effects (dry mouth, constipation, hepatotoxicity); Endocrine effects (thirst, polyuria, hyperglycemia)

Special Instructions

  • Assess serum Na concentration and neurologic status especially during initiation and after titration
  • Carefully monitor patient’s fluid intake, urine volume, serum Na level and for occurrence of clinical symptoms (eg thirst, dehydration)
  • Contraindicated in cases of urgent need to raise serum Na acutely, in hypernatremia, in patients unable to autoregulate fluid balance
  • Discontinue treatment if serum Na is increased above normal range, if significant signs and symptoms of dehydration and hypovolemia are present
  • Use with caution in hyperkalemia or drugs that increase serum K, co-administration with hypertonic saline solutions
1Combinations of Spironolactone and Hydroflumethiazide, and Spironolactone and Furosemide are available. Please see the latest MIMS for specific formulations and prescribing information.
2Combination with Spironolactone is available. Please see the latest MIMS for specific formulations and prescribing information.
3Combination with Hydrochlorthiazide is available. Please see the latest MIMS for specific formulations and specific prescribing information.
4Combination with Amiloride or Candesartan is available. Please see the latest MIMS for specific formulations and specific prescribing information.


Nitrates (Oral)



Drug Available Strength Dosage Remarks
Glyceryl trinitrate (Nitroglycerin, GTN, NTG) 400, 500, 600 mcg sublingual (SL) tab 400-600 mcg SL every 5 minutes until cessation of pain or side effects occur
Max dose: 3 doses within 15 minutes            		 Adverse Reactions
  • CNS effects (headache, lightheadedness, dizziness, syncope, vertigo, restlessness, confusion); rarely CV effects (tachycardia, hypotension, flushing, palpitation); GI effects (nausea and vomiting, bowel incontinence, xerostomia)
Special Instructions
  • Nitrate-free interval is recommended in patients on long-term therapy with nitrates to decrease the risk of nitrate tolerance
  • Avoid in patients with severe hypotension, hypovolemia, marked anemia, heart failure due to obstruction or raised intracranial pressure due to head trauma or hemorrhage
  • Use with caution in patients with severe renal or hepatic dysfunction, hypothyroidism, malnutrition, mitral valve prolapse, arterial hypoxemia, glaucoma or hypothermia
  • Co-administration with phosphodiesterase inhibitors (eg Sildenafil) is contraindicated within 24-hour interval after taking a nitrate preparation
400 mcg/dose SL spray 1-2 sprays (400-800 mcg) SL, closing the mouth after spraying
Max dose: 3 doses within 15 minutes 
Isosorbide dinitrate 5 mg, 10 mg SL tab 5-10 mg SL every 2-3 hours until cessation of pain or side effect occurs 
10 mg tab  30-160 mg/day PO in divided doses
Max dose: 240 mg/day 
20 mg retard tab  20 mg PO 12 hourly 
40 mg retard tab  40 mg PO 12 hourly 
1.25 mg/dose buccal spray  1-3 sprays (1.25-3.75 mg) into the buccal cavity, waiting 30 seconds between sprays
Do not inhale medication 
Isosorbide 5-mononitrate (Isosorbide mononitrate)  20 mg/tab  20 mg PO 12 hourly
Max dose: 120 mg/day 
50 mg/cap 50 mg PO 24 hourly 
May increase to 100 mg PO simultaneously
60 mg/tab  30-60 mg PO 24 hourly
Max dose: 120 mg/day 

Vasodilators Used in Cardiac Diseases


Drug Dosage Remarks
Hydralazine1 In combination w/ Isosorbide dinitrate:
Initial dose:
25 mg PO 6-8 hourly
May increase every ≥1-2 weeks if needed
Maintenance dose:
50-75 mg PO 6 hourly		 Adverse Reactions
  • Typically subside with continued therapy: CV effects (tachycardia, palpitations, angina, flushing); GI effects (anorexia, nausea/vomiting, diarrhea); Other effects (dizziness, nasal congestion)
  • Other CV effects (postural hypotension, fluid retention, edema); Other effects (weight gain, tremor, conjunctivitis, muscle cramps, lacrimation)
Special Instructions
  • Avoid in patients with severe tachycardia, HF with high cardiac output, dissecting aortic aneurysm, cor pulmonale or myocardial insufficiency due to mechanical obstruction (eg aortic stenosis, mitral stenosis, constrictive pericarditis), idiopathic SLE and related disorders
  • Use with caution in patients with ischemic heart disease, recent MI, cerebrovascular disorders, impaired renal or hepatic function
  • CBC, antinuclear antibody determinations and urinalysis should be done periodically during long-term therapy
  • Monitor BP and heart rate after initiation and during dose titration
Isosorbide dinitrate1 Use in combination with Hydralazine:
Initial dose:
20 mg PO 8 hourly x 2-4 weeks
If tolerated, increase dose to
Maintenance dose:
40 mg PO 8 hourly
Max dose: 120 mg/day		 Adverse Reactions
  • CNS effects (headache which usually decreases with long-term administration, lightheadedness, dizziness, syncope, confusion, weakness, restlessness, vertigo); rarely CV effects (palpitations, tachycardia, hypotension, flushing); GI effects (nausea/vomiting, abdominal pain, bowel incontinence, xerostomia)
  • Nitrate tolerance usually develops with long-term use and dosing with adequate nitrate-free interval is recommended
Special Instructions
  • Avoid in patients with severe hypotension, hypovolemia, marked anemia, HF due to obstruction or raised intracranial pressure due to head trauma or hemorrhage
  • Use with caution in patients with severe renal or hepatic dysfunction, hypothyroidism, malnutrition or hypothermia
  • Co-administration with phosphodiesterase inhibitors (eg Sildenafil) are contraindicated
  • Monitor BP and heart rate after initiation and during dose titration
Soluble Guanylate Cyclase Stimulator
Vericiguat 2.5 mg PO 24 hourly
May double the dose every 2 weeks to up to
Maintenance dose:
10 mg PO 24 hourly
Adverse Reactions
  • CV effect (hypotension); CNS effects (syncope, headache); GI effects (nausea/vomiting, dyspepsia, GERD); Other effect (anemia)
Special Instructions
  • Contraindicated in pregnancy, patients with concomitant use of other soluble guanylate cyclase stimulators
  • Breastfeeding or concomitant use of PDE-5 inhibitors is not recommended
  • Monitor BP and CBC for anemia
1The combination of Hydralazine and Isosorbide dinitrate should not be used for the treatment of HF in patients who have no prior use of ACE inhibitor and should not be substituted for ACE inhibitor in patients who are tolerating ACE inhibitors without difficulty.

Other Cardiovascular Drugs


Drug Dosage Remarks
Levosimendan Individualize dosage
Initial dose:
6-12 mcg/kg IV over 10 minutes followed by
Continuous infusion:
0.1 mcg/kg/min IV for 24 hours If tolerated and an increased hemodynamic effect is required, may increase to 0.2 mcg/kg/min
Rate of infusion may be decreased to 0.05 mcg/kg/min or discontinued if the response is deemed excessive 		Adverse Reactions
  • Hematologic effect (decreased Hb): Metabolic effect (hypokalemia); CNS effects (dizziness, headache); CV effects (hypotension, myocardial ischemia, extrasystoles, AF, tachycardia, ventricular tachycardia); GI effects (nausea and vomiting)
Special Instructions
  • Contraindicated in patients with severe renal or hepatic impairment, significant mechanical obstructions affecting ventricular filling or outflow or both, severe hypotension and tachycardia, history of torsades de pointes
  • Use with caution in patients with mild to moderate renal or hepatic impairment, ischemic CV disease and concurrent anemia, tachycardia or AF with rapid ventricular response, ongoing coronary ischemia, acute HF related to a recent onset of a non-cardiac condition, serious deterioration of HF after surgery and severe HF awaiting heart transplantation; concomitant use with other inotropic agents (except Digoxin) or QTc-prolonging drugs
  • Monitor serum K levels, changes in BP or heart rate
Ubidecarenone
(Coenzyme Q10, Ubiquinone-10)		 Adjunctive therapy:
30-200 mg PO 24 hourly		 Adverse Reactions
  • GI effects (nausea, epigastric pain, heartburn, diarrhea); Other effects (appetite suppression, rash, sleep disturbances)
Special Instructions
  • Monitor INR if taken concomitantly with Warfarin

Disclaimer

All dosage recommendations are for non-pregnant and non-breastfeeding women and non-elderly adults with normal renal and hepatic function unless otherwise stated. 
Not all products are available or approved for above use in all countries.
Products listed in the Drug Summary are based on indications stated in the locally approved product monographs. 
Please refer to local product monographs in Related MIMS Drugs for country-specific prescribing information.  

Related MIMS Drugs