Heart Failure

How to read this summary

• Canadian sources come first, US sources second. Each point has a source tag like ^[S1] or ^[U1]. The full list of tags is at the end.
• "WARNING" marks a conflict or an old document. "Unconfirmed" means it could not be verified in the sources used. Never trust an unconfirmed item without checking.
• PEBC follows Canada. When Canada and the US differ, the Canadian answer is the exam answer.
• Page numbers for the CCS pocket guides are the printed page numbers of the guides.

1. What is heart failure? (the pump and the garden hose)

• Heart failure (HF) means the heart cannot pump enough blood for the body, or can only do it with high pressure inside. Core symptoms are shortness of breath, swelling (ankles, feet, legs, belly), tiredness or weakness, weight gain, cough or wheeze, poor appetite, palpitations and confusion ^{[S1 p14]}.
• Daily-life picture: the heart is a water pump in a garden. If the pump is weak (HFrEF), water backs up in the hose. If the pump muscle is stiff and cannot relax and fill (HFpEF), pressure also builds up behind it. Backed-up water leaks into the lungs (breathlessness) and the legs (swelling). Diuretics are like opening a drain to lower the water level. Drugs such as ACEi, ARNI, beta-blockers, MRAs and SGLT2 inhibitors protect the pump from wearing out over the years.
• HF is a long-term (chronic) problem. Most people take a combination of drugs for life ^{[S1 p13; S2 p6]}.

2. Types of HF (by ejection fraction, EF)

EF (LVEF) is the percent of blood the left ventricle pushes out with each beat.

• Why CCS joined HFmrEF and HFpEF: outcomes and treatment responses are similar across LVEF above 40% ^{[S1 p2]}.
• WARNING: The older CCS 2021 pocket guide writes "HFmEF" (mid-range EF, 41-49%) and "HFpEF" (50% or more) ^{[S2 p2]}; the US text writes "HFmrEF" (mildly reduced EF). The 2025 CCS update (Can J Cardiol 2025;41(10):1857-1874) replaces them with HFnrEF for drug decisions ^{[S1; S19]}. Know both words for the exam.
• How HFnrEF is diagnosed - all three must be present ^{[S1 p14]}: 1. Symptoms or signs of HF. 2. LVEF above 40% on dedicated imaging (echocardiogram, cardiac MRI or MUGA). 3. Evidence of high filling pressures: at least one of raised BNP/NT-proBNP, structural heart disease or diastolic dysfunction on imaging, or hemodynamic confirmation.
• US note: all patients with current or prior HF, whatever the EF, should be considered for guideline-directed medical therapy (GDMT). Continue GDMT in HFimpEF to prevent relapse ^[U1].

3. Causes and triggers

Causes (CCS etiology chart) ^{[S1 p16-17; S2 p2-3]}:

• Common: coronary artery disease (heart attack damage), high blood pressure with thick heart muscle (LVH), valve disease, fast irregular rhythms (tachyarrhythmia), congenital heart disease, pericardial disease.
• Toxins: alcohol, amphetamines, cocaine, steroids, chemotherapy, heavy metals, radiation therapy ^{[S1 p17]}.
• Pregnancy-related: peripartum cardiomyopathy (PPCM), pre-eclampsia, gestational diabetes history ^{[S1 p17]}.
• Others on the CCS chart: family history of dilated cardiomyopathy, hypertrophic cardiomyopathy, amyloidosis, hemochromatosis, myocarditis, sarcoidosis, thyroid disease, diabetes, obesity, thiamine or selenium deficiency ^{[S2 p3]}.
• Risk factors to ask about: hypertension, ischemic heart disease, valve disease, diabetes, heavy alcohol or substance use, chemotherapy or radiation, family history, smoking, high cholesterol ^{[S2 p1]}.

Drugs that can cause or worsen HF (see section 8 for the full "avoid" table): NSAIDs, thiazolidinediones, non-dihydropyridine CCBs in HFrEF, some antiarrhythmics, some chemotherapy ^{[S16; U3; U2]}.

Triggers of a flare-up (decompensation): the CCS uses the words "exacerbating factors", "comorbidities" and "drugs" in its history checklist ^{[S1 p15]}. A detailed list of triggers (missed pills, high-salt meals, infection, new arrhythmia, new NSAID, and so on) is general teaching that was not confirmed in the sources used. Treat it as unconfirmed.

Daily-life example: a patient on diuretic eats very salty soup for a week and takes ibuprofen for back pain. Salt and NSAIDs both make the body hold water, so the "hose" backs up again.

4. Symptoms and signs

5. Stages (ACC/AHA) and NYHA classes

Stages show how the disease develops. Stage A and B patients have no symptoms yet.

• Stage definitions: ^{[U1 (stages A and B named); U7 secondary summaries for the full wording]}. WARNING: it was not possible to open the primary AHA/ACC guideline (access blocked), so stage wording rests on secondary summaries.
• NYHA class (symptoms today; can go up or down) ^{[U8 secondary, matches several other pages seen]}:
• Class I: symptoms only with more than ordinary activity (no limit in daily life).
• Class II: symptoms with ordinary activity (slight limit).
• Class III: symptoms with less than ordinary activity (marked limit); comfortable at rest.
• Class IV: symptoms at rest.
• Health Canada drug labels use NYHA classes. Examples: sacubitril/valsartan NYHA II-III ^[S3]; ivabradine NYHA II-III ^[S5]; eplerenone NYHA II ^[S10].

6. Diagnosis basics and monitoring labs

• First look: history, exam (vitals, weight, volume status), chest x-ray, ECG, labs (CBC, electrolytes, renal function, urinalysis, glucose, thyroid function), then BNP or NT-proBNP and echocardiogram ^{[S2 p4; S1 p15]}.
• CCS 2021 adds ferritin, TSH and troponin to the routine labs for the cause work-up ^{[S2 p2]}.
• Ambulatory (outpatient) cut-offs for "HF likely": NT-proBNP above 125 pg/mL or BNP above 50 pg/mL, then do an echo. Below these, work up other causes ^{[S2 p5]}. Natriuretic peptides are not available in all Canadian jurisdictions ^{[S2 p5]}.
• Acute (emergency) cut-offs ^{[S2 p1, p17]}:

These numbers are for acute (decompensated) HF, not stable HF ^{[S2 p1]}. - Follow-up use: in outpatients a rise of more than 30% from clinic baseline means closer follow-up (with or without stronger therapy). In hospital, a fall of more than 30% from admission value helps decide discharge ^{[S2 p16]}. - Echo tells the EF. A normal EF on a routine echo does not rule out HF; judgment is needed ^{[S2 p5]}. - Monitoring labs for drugs (details in section 7): potassium, creatinine/eGFR, sodium, magnesium for diuretics and digoxin, BP, heart rate, weight.

7. Drug treatment

7.1 Big picture

HFrEF (LVEF 40% or less) - CCS 2021 ^{[S2 p10]}:

• Start standard therapies as soon as possible and raise doses every 2-4 weeks to target or maximum tolerated dose over 3-6 months.
• Four foundation groups: ARNI (or ACEi/ARB, then switch to ARNI), beta-blocker, MRA, SGLT2 inhibitor. Add a loop diuretic as needed for congestion at the lowest dose that keeps the patient "dry" (euvolemic).
• Add-ons (for persistent NYHA II-IV symptoms despite the four): ivabradine (sinus rhythm, HR 70 or more per CCS chart), vericiguat (recent HF hospitalization), hydralazine + isosorbide dinitrate (H-ISDN) (cannot take ARNI/ACEi/ARB, or Black patients with high symptom burden), digoxin (AF with poor rate control, or symptoms despite other therapy) ^{[S2 p10, p12-13]}.
• Also: treat other conditions, teach self-care and exercise, device therapy (ICD/CRT) after at least 3 months of optimal drugs when LVEF 35% or less, advance care planning ^{[S2 p10, p26]}.

HFnrEF (LVEF above 40% and symptoms) - CCS/CHFS 2025 ^{[S1 p3-4]}:

• The CCS says there is no proven order of starting inside a tier; use shared decision-making ^{[S1 p3]}.
• Beta-blockers and ACEi are not in the CCS 2025 HFnrEF tiers ^{[S1 p3]}. In practice, use them only for another reason (for example hypertension or after a heart attack) - this last statement is a teaching comment, unconfirmed.
• US 2022: SGLT2i class 2a for HFmrEF and HFpEF; ARNI/ACEi/ARB/MRA/beta-blocker weaker (2b) in that EF range ^{[U1; U2 secondary]}. WARNING: the US 2022 guideline is older (2022) than CCS 2025; the CCS gives stronger advice for MRA. PEBC follows Canada.

7.2 Dose table (start / target)

Source for HFrEF doses: CCS 2021 pocket guide, "doses shown in large trials" ^{[S2 p7]}. Source for HFnrEF doses: CCS 2025 ^{[S1 p6-9]}. Health Canada label (PM) numbers are shown where the labels were opened.

7.3 ACEi, ARB and ARNI (RAAS drugs)

• Job: relax the "hose" (lower pressure) and stop harmful hormone signals that scar the heart.
• Sacubitril/valsartan (Entresto) - Health Canada label ^[S3]:
• Indication: HFrEF, NYHA II-III, to lower CV death and HF hospitalization, used in place of an ACEi or ARB with other HF drugs.
• 36-hour washout after the last ACEi dose because of angioedema risk. This is a contraindication to taking them together. No washout is needed when coming from an ARB.
• Contraindicated: recent symptomatic hypotension, any ACEi, history of angioedema with ACEi/ARB, hereditary or idiopathic angioedema, aliskiren in diabetes or eGFR below 60, pregnancy and breastfeeding, hypersensitivity.
• Black patients appear to have a higher angioedema risk (PARADIGM-HF: 2.4% vs 0.5% with enalapril) ^[S3].
• Start 24/26 mg BID if on low-dose ACEi/ARB, age 75 or more, or low SBP; moderate hepatic impairment (Child-Pugh B) start 24/26 mg BID; severe renal impairment (eGFR below 30) and Child-Pugh C: not recommended. Raise every 2-4 weeks ^[S3].
• Potassium: check before and during treatment; patients with K above 5.2 mmol/L at start were not studied ^[S3]. Do not give with other ARBs ^[S3].
• CCS 2021 conversion chart: its footnote says 50 mg BID = 24/26 mg, 100 mg BID = 49/51 mg and 200 mg BID = 97/103 mg ^{[S2 p14]}. The extracted chart layout is scrambled, so it could not be confirmed which exact start dose and titration time (3 weeks or 6 weeks) belong to each box: unconfirmed. Use the clearer CCS 2025 table below.
• CCS 2025 table ^{[S1 p9-10]}: on higher-dose ACEi (enalapril 10 mg/day or more, lisinopril 10 or more, perindopril 4 or more, ramipril 5 or more) wait 36 hours, then 49/51 mg BID; on higher-dose ARB (candesartan 16 or more, irbesartan 150 or more, losartan 50 or more, olmesartan 10 or more, telmisartan 40 or more, valsartan 160 or more) start 49/51 mg BID with no washout; low or medium dose ACEi/ARB or ACEi/ARB-naive: 24/26 mg BID (36-hour washout if on ACEi); SBP 120 or more can start 49/51, SBP 100-120 start 24/26; target 97/103 mg BID.
• CCS 2025: after ARNI start, check creatinine, potassium and BP at 1 week. Increase every 2-4 weeks if stable and SBP 100 mmHg or more. Consider reducing or stopping if creatinine rises over 30%, K above 5.4, or symptomatic hypotension ^{[S1 p9-10]}.
• WARNING (label vs guideline): the Health Canada label used covers HFrEF only. The CCS 2025 weakly suggests ARNI for LVEF above 40% ^{[S1 p4]}. no Health Canada indication for LVEF above 40% was found; treat this as guideline use beyond the label (unconfirmed).
• ACE inhibitors and ARBs (ramipril label as an example) ^[S14]:
• Contraindicated in pregnancy, hyperkalemia, with sacubitril/valsartan, with aliskiren in diabetes, and in some patients with heart failure who are hypotensive.
• Dry persistent cough is a known effect that goes away after stopping or lowering the dose.
• ACEi can injure or kill the developing fetus; stop when pregnancy is found.
• ARB (candesartan, valsartan) is used when ACEi is not tolerated or when ARNI is unavailable ^{[S1 p3; U1]}.
• Monitoring: BP, creatinine and potassium at about 1 week after start and after each dose change (the 1-week timing is explicit in the CCS 2025 MRA and ARNI tables ^{[S1 p7, p9]}; for ACEi/ARB it is the same idea but no explicit CCS number for ACEi/ARB was found - unconfirmed).

7.4 Beta-blockers

• Job: slow and calm the heart so it wastes less energy and is protected from stress hormones.
• Evidence-based choices in the CCS table: carvedilol, bisoprolol, metoprolol succinate (CR/XL) ^{[S2 p7]}. Nebivolol is NOT in the CCS table; its HF role was not verified, so unconfirmed.
• Carvedilol Health Canada label ^[S11]:
• Indicated for mild, moderate or severe HF (ischemic or non-ischemic) to improve survival and reduce hospitalization, usually with a diuretic and ACE inhibitor.
• Patients should be clinically stable for 4 weeks before starting, and on stable diuretic and ACEi doses.
• Take with food to slow absorption and reduce dizziness. Dizziness or low BP can occur within 2 hours after a dose, especially at start and at dose increases.
• Do not increase while HF symptoms or vasodilation (dizziness, low BP) are not settled. Transient worsening of HF can be treated by increasing diuretic, lowering the carvedilol dose or, if needed, stopping.
• Contraindicated: decompensated HF needing IV inotropes, asthma/bronchospasm, AV block 2nd or 3rd degree or sick sinus (unless pacemaker), cardiogenic shock, severe hypotension, severe bradycardia, primary obstructive valvular disease, clinically manifest hepatic impairment.
• Heart rate lower than 68 bpm: studied poorly; weigh risk and benefit.
• Bisoprolol: WARNING (label vs guideline). The Canadian bisoprolol label used lists mild to moderate HYPERTENSION as the indication, notes caution in severe HF, and says doses above 10 mg/day in HF are not established ^[S12]. The CCS lists it as an evidence-based HF beta-blocker, so HF use is guideline use ^{[S2 p7]}. Contraindicated: acute HF or decompensation needing IV inotropes, cardiogenic shock, 2nd/3rd degree AV block, sick sinus, heart rate below 60 before start, SBP below 100, severe asthma/COPD ^[S12].
• Counselling for all: do not stop suddenly (general teaching, unconfirmed in the labels used); report weight gain, slow pulse, dizziness, fainting.
• Start low, go slow: raise every 2-4 weeks (CCS) ^{[S2 p10]}; reassess before each increase (carvedilol label ^[S11]).

7.5 MRAs (spironolactone, eplerenone, finerenone)

• Job: block aldosterone, a hormone that makes you hold salt and water and scars the heart. They are mild water pills that keep potassium IN.
• CCS 2025 rules ^{[S1 p7-8]}:
• Check creatinine/eGFR and potassium 1 week after start and after every dose change; after any other drug change or illness that affects kidneys/potassium; and about every 3 months when stable.
• Raise dose every 2-4 weeks toward target if K below 5.0 mmol/L, eGFR above 30 and SBP above 95 mmHg without symptoms.
• Consider lowering or stopping if creatinine rises over 30%, K above 5.4, or symptomatic hypotension. Stop if K is 6.0 or more on a non-hemolyzed sample.
• Start lower (12.5 mg spironolactone or eplerenone; 10 mg finerenone) if eGFR 30-59, frail/elderly, or high hyperkalemia risk.
• Spironolactone Health Canada label ^[S9]: contraindicated if GFR below 30, hyperkalemia, pregnancy, breastfeeding, Addison disease, anuria, and with eplerenone, heparin/LMWH, or mitotane. Avoid potassium supplements, salt substitutes and high-potassium foods (bananas, prunes, raisins, orange juice). Gynecomastia can occur; the label says to stop the drug if it develops (switching to eplerenone is a common option but this was not confirmed in a source: unconfirmed). Lithium levels can rise.
• WARNING (label vs guideline): the Canadian Aldactone label describes HF use as an edema/sodium-retention treatment when other measures are not enough ^[S9]. The survival-benefit use at 12.5-50 mg daily comes from the CCS guideline ^{[S2 p7]}.
• Eplerenone (Inspra) Health Canada label ^[S10]: indicated for NYHA II systolic chronic HF and for HF after a heart attack with EF 40% or less. No mortality reduction was seen in patients 75 or older. Do not give if K above 5.0 mmol/L at start or eGFR below 30. Contraindicated with potassium-sparing diuretics, potassium supplements and strong CYP3A4 inhibitors (ketoconazole, itraconazole, nefazodone, telithromycin, clarithromycin, ritonavir, nelfinavir). Measure K before starting, within 1 week and at 1 month after start or dose change, then periodically.
• Finerenone (Kerendia) Health Canada label ^[S6]: HF with LVEF 40% or more is an approved indication (Jan 2026 label). Do not start if K above 5.0 mmol/L or eGFR below 25. Recheck K and eGFR at 4 weeks. Dose table for HF: if K below 5.0 raise (10 to 20 to 40 mg) when eGFR has not fallen more than 30%; K 5.0 to below 5.5 keep dose; K 5.5 to below 6.0 withhold or reduce; K 6.0 or more withhold. Contraindicated with strong CYP3A4 inhibitors (itraconazole, ketoconazole, ritonavir, nelfinavir, cobicistat, clarithromycin, telithromycin, nefazodone) and Addison disease.
• US: FDA approved finerenone for HF with LVEF 40% or more in July 2025 ^[U5].

7.6 SGLT2 inhibitors (dapagliflozin, empagliflozin)

• Job: make the kidney drop extra sugar and salt into the urine. It acts like a gentle diuretic and protects the heart and kidney, whether or not the patient has diabetes. In HFrEF: CCS standard therapy ^{[S2 p10]}. In LVEF above 40%: STRONG recommendation ^{[S1 p4]}.
• Health Canada labels:
• Dapagliflozin (Forxiga) HF indication: adults, with standard care, to reduce CV death, HF hospitalization and urgent HF visits; NOT for emergency treatment of acute HF. Dose 10 mg once daily. Contraindicated in patients on dialysis. Starting is not recommended if eGFR is below 25. Check kidney function before and regularly after starting (more often if eGFR below 60). Stop if dialysis starts. Stop 3 days before major surgery or prolonged fasting where possible. Lithium levels may fall ^[S7].
• Empagliflozin (Jardiance) HF indication: adults, as an adjunct to standard care; not recommended for emergency treatment of acute HF. Dose 10 mg daily. 10 mg can be used regardless of kidney function, but trials did not include eGFR below 20 and starting on dialysis is not recommended. Use caution with diuretics, especially loop diuretics, because of volume depletion. Interrupt at least 3 days before major surgery. Patients hospitalized for acute HF should be stabilized first ^[S8].
• Both: boxed warning about ketoacidosis. It can occur when glucose is only mildly raised or normal-looking. Check for ketoacidosis if nausea, vomiting, abdominal pain, confusion, excessive thirst, unusual tiredness or trouble breathing ^{[S7; S8]}. The labels differ: the Forxiga label describes ketoacidosis in patients with type 2 diabetes, and the Jardiance label also says cases were reported in people without type 2 diabetes (see "Label vs guideline", section 7.13). Do not use in type 1 diabetes (Forxiga label) ^[S7]. Genital yeast infections and rare necrotizing fasciitis of the perineum (Fournier gangrene) are warnings (Jardiance label) ^[S8].
• Pregnancy: dapagliflozin must not be used in pregnancy ^[S7].
• Counselling: stay hydrated; "sick-day" pause if vomiting, diarrhea or unable to eat or drink (the label risk is dehydration/volume depletion and ketoacidosis; the exact "sick day" wording is from general practice and is unconfirmed in the labels used); genital hygiene; report pain/redness in the genital area.
• Daily-life example: a patient with the flu who cannot drink should call the pharmacy or doctor about pausing the SGLT2 inhibitor, the diuretic and the ACEi/ARB because of dehydration (unconfirmed as exact guideline wording).

7.7 Diuretics (loop and thiazide)

• Job: the drain. They relieve congestion (swelling, breathlessness) but do not by themselves prolong life. Use the lowest dose that keeps the patient euvolemic ("dry weight") ^{[S2 p10]}.
• CCS acute doses ^{[S2 p18-20]}: IV furosemide 20-80 mg bolus, or infusion 5-20 mg/h (after a 20-40 mg bolus). Higher bolus doses work better than more frequent small doses.
• If response is poor: add a different type of diuretic (thiazide or spironolactone), for example metolazone 1.25-5 mg 1-7 times a week or hydrochlorothiazide 25-50 mg, used with caution; consider inotropes if poor perfusion; refer for ultrafiltration/dialysis if the kidney blocks diuresis ^{[S2 p20]}.
• Daily response rule (CCS chart) ^{[S2 p19]}: if 24-hour weight change is under 0.5 kg or urine under 3 L, raise the loop dose by about 50%; if 0.5-1.5 kg loss and 3-5 L, continue; if over 1.5 kg and over 5 L, consider reducing the dose by 25-50%.
• Oral starting and maximum doses of furosemide, torsemide or bumetanide: not found in the sources used. Unconfirmed.
• Watch: potassium and magnesium (low K/Mg makes digoxin toxicity more likely ^[S13]), sodium, creatinine, BP, weight. Diuretics may need frequent re-adjustment ^{[S2 p6]}.

7.8 Ivabradine (Lancora)

• Job: slows the heart's natural pacemaker (the sinus node) without lowering BP much.
• Health Canada indication ^[S5]: stable chronic HF, LVEF 35% or less, NYHA II-III, in sinus rhythm with resting HR 77 bpm or more, with standard HF therapy, to reduce CV death and HF hospitalization.
• WARNING: the CCS 2021 chart says "HR above 70 bpm" ^{[S2 p10, p12]}, but its footnote and the Health Canada label say 77 bpm or more ^{[S2 p10 footnote; S5]}. Use 77 for the Canadian label; contraindicated if resting HR is below 70 ^[S5].
• Dosing ^[S5]: 5 mg BID start. After 2 weeks: HR over 60 raise by 2.5 mg BID (max 7.5 mg BID); HR 50-60 keep; HR below 50 or symptoms of bradycardia lower by 2.5 mg BID (stop if already at 2.5 mg BID). Take twice daily about 12 hours apart.
• Contraindications ^[S5]: HR below 70 before start, acute or unstable HF, long QT, cardiogenic shock, acute MI, severe hypotension (below 90/50), severe liver impairment, sick sinus, SA block, 3rd-degree AV block, pacemaker dependence, strong CYP3A4 inhibitors (for example ketoconazole, itraconazole, clarithromycin, ritonavir), verapamil or diltiazem, pregnancy and breastfeeding, women of childbearing age without contraception.
• Cautions: atrial fibrillation risk increased (monitor), not recommended in AF; avoid grapefruit and St John's wort ^[S5]. Visual flashes (phosphenes) and bradycardia are the typical side effects ^{[S2 p12]}.

7.9 Vericiguat (Verquvo)

• Job: helps the body's own blood-vessel relaxing signal (sGC stimulator).
• WARNING: the CCS 2021 chart says vericiguat is "not yet approved for use in Canada" ^{[S2 p10 footnote]}. That is out of date: Health Canada approved it (initial approval April 27, 2023) ^[S4].
• Health Canada indication ^[S4]: symptomatic chronic HF with reduced EF in adults stabilized after a recent decompensation needing hospitalization and/or IV diuretics, with standard HF therapy.
• Dose ^[S4]: 2.5 mg once daily with food; double about every 2 weeks to 10 mg once daily. Do not start if SBP below 100 mmHg. Reduce or interrupt if symptomatic hypotension or SBP below 90.
• Contraindicated with other sGC stimulators such as riociguat ^[S4]. PDE-5 inhibitors (for example sildenafil) not recommended because of hypotension risk; long-acting nitrates have limited experience ^[S4]. CCS: do not combine with nitrate therapy ^{[S2 p12]}.
• Pregnancy: not recommended in pregnancy and in women of childbearing age not using contraception; rule out pregnancy before starting ^[S4].
• Renal: no dose adjustment if eGFR is 15 mL/min/1.73 m2 or more (not on dialysis). Not studied, and not recommended, if eGFR is below 15 or on dialysis ^[S4]. CCS also notes no safety data below 15 ^{[S2 p12]}.

7.10 Hydralazine + isosorbide dinitrate (H-ISDN)

• Use when ARNI/ACEi/ARB cannot be used because of worsening kidney function or high potassium, or as an extra for Black patients with high symptom burden on best therapy ^{[S2 p10, p13]}.
• Doses in section 7.2. Side effects: symptomatic hypotension; hydralazine can cause a lupus-like syndrome. Hydralazine or nitrate alone has not shown HF outcome benefit ^{[S2 p13]}.

7.11 Digoxin

• Use: AF with poor rate control despite beta-blocker, or persisting symptoms despite other drugs ^{[S2 p13]}. It improves symptoms and hospitalizations but has no effect on mortality ^[S13].
• Narrow therapeutic index. Toxicity: nausea, vomiting, AV block, ventricular arrhythmias ^{[S2 p13]}. Avoid in AV nodal disease; generally contraindicated in severe renal impairment (CCS) ^{[S2 p13]}. The PM (pms-Digoxin, 2022) says renal impairment needs smaller maintenance doses and that low K, low Mg or high Ca can predispose to toxicity, and low Ca can blunt the effect ^[S13].
• Interactions (PM): quinidine, verapamil, amiodarone, propafenone, erythromycin/clarithromycin raise digoxin effect or levels; K-lowering drugs (diuretics, corticosteroids, amphotericin B) raise toxicity risk ^[S13].
• The digoxin PM used is the 2022 pms-Digoxin label ^[S13]; the Lanoxin brand label was not found in the Health Canada portal search, so check it if you need brand wording.

7.12 GLP-1 receptor agonists in HFnrEF (new in 2025)

• Semaglutide or tirzepatide, weekly injection, for NYHA II-IV HF with LVEF 45% or more and BMI 30 or more: weak recommendation to lower HF hospitalization and improve quality of life ^{[S1 p4, p11]}.
• Do NOT use if: personal or family history of medullary thyroid cancer or MEN2, type 1 diabetes, pregnant or breastfeeding, history of pancreatitis or pancreatic cancer ^{[S1 p11]}. Caution with insulin or insulin secretagogues, and poor oral intake or nausea/vomiting ^{[S1 p11]}.
• In diabetes with A1c 8% or less, consider lowering the secretagogue or cutting insulin 10-20% to prevent hypoglycemia ^{[S1 p11]}. (The printed sign before 8% could not be read in the pocket guide; check the original.)
• GI side effects: stay on or reduce the dose, wait more than 4 weeks before the next step, or pause. Eat smaller, more frequent, low-fat meals, avoid lying down after eating ^{[S1 p12]}.
• Follow-up: A1c if diabetic, diet, weight, GI symptoms, retinopathy, quality of life ^{[S1 p11]}.

7.13 Label vs guideline: where Health Canada and the CCS disagree

Show both. Do not pick one silently. For the exam, the Health Canada label is the safer answer for dosing and contraindication questions; discuss real patients with the prescriber.

8. Drugs to AVOID or use with great care in HF

• The class wording (class 3 Harm and so on) in this table is US-only. The Canadian sources used support only the label-based rows (pioglitazone, Multaq, ivabradine, MRA, ARNI).
• WARNING: items marked ^[U3] come from a Pharmacy Times overview (secondary source). The primary AHA/ACC/HFSA guideline was blocked, so their class labels are only given where a guideline summary showed them (NSAIDs ^[U2]). Check the primary text before relying on the class wording.

9. Vaccines

• CCS: annual influenza vaccine and periodic pneumococcal vaccine for people with HF ^{[S2 p6]}.
• NACI influenza: one dose of seasonal vaccine each year for adults and children 9 years and older; flu shots may add protection against cardiovascular events in people with cardiovascular disease (NACI 2025-26 summary, only seen in a search extract: partly unconfirmed) ^[S18].
• NACI pneumococcal (Nov 15, 2024): one dose of Pneu-C-20 or Pneu-C-21 for adults 65 and older, and for adults under 65 at increased risk, which includes chronic heart disease needing regular medication, chronic heart failure ^[S17].
• Other vaccines (COVID-19, RSV, shingles): NACI wording for HF was not verified. Unconfirmed.

10. Non-drug care and counselling

• Sodium: "restriction between 2 g and 3 g per day is reasonable" ^{[S1 p13; S2 p6]}. US 2022: for stage C, avoiding excessive sodium is reasonable (class 2a, C-LD) ^[U6]. The SODIUM-HF trial (target below 1500 mg/day) has not changed most practice, and the evidence base is weak ^[U6]. Daily-life example: skip canned soup, deli meat and chips; read labels for "sodium".
• Fluid: the CCS chart for acute HF includes sodium and fluid restriction ^{[S2 p20]}. A daily fluid limit for chronic stable HF: not found in the sources used. Unconfirmed.
• Weigh every morning (after the toilet, before breakfast, same scale) "if fluid retention" ^{[S1 p13]}. Gain of more than 2 kg in 2 days is a warning ^{[S1 p13; S2 p6]}. Daily-life example: like checking a bathtub water level every morning.
• Warning signs to report (CCS) ^{[S2 p6]}: more breathless with less effort, during sleep or lying flat; tiredness with less effort; more belly or leg swelling; breathless at rest; weight gain over 2 kg in 2 days; light-headed or faint; long palpitations; confusion; chest pain that does not go away with rest or medicine, or is getting worse.
• Emergency: breathless at rest or chest pain that does not settle (the CCS lists these as warning signs; calling 911 is a teaching comment: unconfirmed as the CCS words).
• Exercise (CCS table, NYHA I-III stable) ^{[S2 p23]}: start 2-3 days a week, aim for 5; start 10-15 minutes, aim for 30; moderate intensity (RPE 3-5, 65-85% of max HR, or 50-75% of peak VO2); resistance 10-20 repetitions with 5-10 lb weights, 2-3 days a week; walking, treadmill, cycle, swimming.
• Risk factor control: control blood pressure and diabetes, stop smoking, obesity counselling ^{[S1 p13]}. Heavy alcohol is a listed cause of cardiomyopathy ^{[S1 p17]}; the exact safe amount of alcohol is unconfirmed.
• Self-care action plan: know your "dry weight", your drug list and your call triggers. Take medications every day; most are lifelong ^{[S1 p13]}. Side effects are often manageable by changing the timing of doses ^{[S1 p13]}.
• Devices: consider ICD/CRT when LVEF is 35% or less after at least 3 months of optimal drugs and NYHA II-IV. An ICD alone is generally not considered in NYHA IV with poor one-year survival, unless a CRT device is planned or advanced therapies are being considered ^{[S2 p26]}.
• Advance care planning: start early and repeat; triggers include hospitalization ^{[S2 p27]}.
• Follow-up frequency ^{[S2 p9]}: high-risk patients every 1-4 weeks (NYHA IIIB-IV, recent hospital stay, during titration); intermediate every 1-6 months; low-risk every 6-12 months.

11. Special situations

11.1 Acute decompensated HF basics (CCS 2021 chart) ^{[S2 p17-22]}

• Goals: find the trigger, relieve symptoms, establish "dry weight", start or optimize chronic therapy, teach, plan follow-up.
• Oxygen: target saturation 92% or more; consider CPAP/BiPAP.
• IV furosemide 20-80 mg bolus or 5-20 mg/h infusion. If SBP over 100: add IV or SL nitroglycerin if poorly responding; SBP 90-100: consider inotrope (dobutamine/milrinone) if low output; SBP under 90: consider dopamine or other vasopressor/dobutamine.
• Consider discharge when symptoms are resolved, vitals stable over 24 hours, back at "dry" weight on oral diuretic for more than 24 hours, chronic oral therapy started or planned, education done, follow-up labs and visits arranged.
• Do not start sacubitril/valsartan during acutely decompensated HF ^[S3]. Dapagliflozin and empagliflozin are not for emergency treatment of acute HF, but patients hospitalized for acute HF should be stabilized and put on HF therapy ^{[S7; S8]}.
• Beta-blockers: carvedilol is contraindicated in decompensated HF needing IV inotropes ^[S11]; bisoprolol is contraindicated in acute HF ^[S12].
• Vericiguat and ivabradine are for patients who are stable ^{[S4; S5]}.

11.2 Renal impairment

• A creatinine rise of more than 30% with MRA or ARNI is a signal to reduce or stop ^{[S1 p8, p10]}. Some rise after starting RAAS drugs happens (teaching comment; the 30% limit is the sourced number).

11.3 Hyperkalemia (potassium too high)

• MRA: K above 5.4 mmol/L = consider reducing or stopping; K 6.0 or more = discontinue ^{[S1 p8]}. ARNI: K above 5.4 = consider reduction or stop ^{[S1 p10]}.
• Finerenone: K 5.5 to below 6.0 withhold or reduce; 6.0 or more withhold; restart only when K below 5.5 (or below 5.0 if it keeps recurring) ^[S6].
• Practical steps from the labels: review potassium supplements, salt substitutes, potassium-sparing diuretics and high-potassium foods ^{[S3; S9]}. Emergency treatment of hyperkalemia (calcium, insulin and glucose, potassium binders): not covered in the sources used. Unconfirmed.

11.4 Pregnancy and breastfeeding

• Peripartum cardiomyopathy and pre-eclampsia are listed causes of HF ^{[S1 p17]}. Specific treatment of PPCM (for example bromocriptine) is not in the sources used: unconfirmed.

11.5 Elderly and frail

• Sacubitril/valsartan: start 24/26 mg BID at age 75 or older (Health Canada) ^[S3]; CCS chart says over 75 ^{[S1 p10]}.
• MRA: start 12.5 mg (or finerenone 10 mg) if frail/elderly ^{[S1 p8]}. Eplerenone: no mortality benefit seen at 75 or older ^[S10].
• Ivabradine: start 2.5 mg BID at 75 or older ^[S5].
• SGLT2i: elderly have more volume-depletion and low BP reports; use caution ^[S8].
• Confusion may be the only symptom in older adults ^{[S2 p1]}.

11.6 Diabetes with HF

• SGLT2 inhibitors help HF with or without diabetes ^{[S1 p4; S7; S8]}. Watch for volume depletion and genital infection, and for ketoacidosis symptoms; not for type 1 diabetes ^[S7].
• Avoid pioglitazone ^[S16]. Saxagliptin and alogliptin raise HF admissions ^[U3].
• GLP-1 RA in HFnrEF with BMI 30 or more: lower insulin or secretagogue doses when A1c is 8% or less ^{[S1 p11]}.
• Diabetes is also a risk factor to control ^{[S1 p13]}.

11.7 Atrial fibrillation with HF

• Anticoagulate AF unless there is a contraindication ^{[S2 p15]}.
• Rate control: beta-blocker first; digoxin for poor control despite beta-blocker ^{[S2 p13]}.
• Avoid: dronedarone (contraindicated in HF) ^[S15]; diltiazem/verapamil in HFrEF ^[U2]; class I agents ^[U3]; ivabradine is not recommended in AF ^[S5].
• Treat AF as a trigger and a comorbidity under CCS recommendations ^{[S1 p3]}.

11.8 Hypotension during titration

• Start low, go slow; separate the dosing time of carvedilol from the ACEi, or temporarily reduce the ACEi dose ^[S11].
• Check volume status: reduce diuretic if the patient is dry and not congested (teaching comment; CCS wording not found: unconfirmed).
• Thresholds: ARNI up-titration needs SBP 100 mmHg or more ^{[S1 p9]}; MRA up-titration needs SBP above 95 without symptoms ^{[S1 p8]}; vericiguat should not start at SBP below 100 and is reduced if symptomatic or below 90 ^[S4]; ivabradine contraindicated below 90/50 ^[S5].
• Dizziness after carvedilol: sit or lie down; take with food ^[S11].

11.9 Drug-induced HF: see section 8. Also check chemotherapy history and heavy alcohol or stimulant use ^{[S1 p17]}.

12. Pharmacist role and when to refer

• Check the whole list: look for NSAIDs, diltiazem/verapamil, pioglitazone, dronedarone, potassium products and salt substitutes, ACEi + ARNI overlap, aliskiren, lithium [section 8 sources].
• Confirm the 36-hour ACEi to ARNI gap and that the ACEi is stopped ^[S3].
• Ask for lab values: K, creatinine/eGFR, Na before and after MRA, ARNI, ACEi/ARB, SGLT2i; remind the patient about the 1-week blood test after changes ^{[S1 p7, p9]}.
• Reinforce daily weights, sodium limits, vaccines and the action plan ^{[S1 p13; S2 p6]}.
• Refer urgently (same day) for: breathless at rest, chest pain that does not settle, fainting, confusion, rapid weight gain with worse swelling ^{[S2 p6]}.
• CCS referral speed for specialists ^{[S2 p8]}: emergent (within 24 hours) for severe/shock/new pulmonary edema; urgent (within 2 weeks) for new HF not improving, NYHA IV, after hospital or ER visit; semi-urgent (within 6 weeks, ideally 4) for stable new diagnosis NYHA II/III; routine (within 12 weeks, ideally 6) for chronic stable HF NYHA I-II. The extracted text of this page was scrambled, so these times should be double-checked on the original: partly unconfirmed.
• Refer for a prescriber to review: HR below 50, SBP below 90, K 5.5 or more, creatinine up more than 30%, symptoms of ketoacidosis, angioedema (lip, tongue or throat swelling) ^{[S1; S3; S7]}.

13. Canada vs US: what differs

14. Ten original practice MCQs

Blueprint area: 1A Clinical Care. Each item is original. Answers and explanations follow the questions.

Q1. A patient with HFrEF has been on enalapril 10 mg twice daily. The prescriber decides to switch to sacubitril/valsartan. What is the correct timing? - A. Start sacubitril/valsartan at the next scheduled enalapril time - B. Wait 12 hours after the last enalapril dose - C. Wait 24 hours after the last enalapril dose - D. Wait at least 36 hours after the last enalapril dose - E. Wait 7 days after the last enalapril dose

Q2. Mrs. R, 66, with HFrEF takes spironolactone 25 mg daily. A 1-week blood test shows potassium 5.6 mmol/L and creatinine up 12% from baseline. What is the best next step? - A. Increase spironolactone to 50 mg to reach the target dose at once - B. Add a potassium supplement to balance the water-pill effect on her potassium - C. Tell the prescriber; reduce or hold the MRA and recheck labs soon - D. Continue unchanged and recheck in 3 months - E. Swap spironolactone for triamterene

Q3. Which patient best fits the Health Canada indication for ivabradine? - A. LVEF 30%, NYHA II, sinus rhythm, HR 82 bpm on a beta-blocker - B. LVEF 30%, permanent atrial fibrillation, HR 82 bpm on a beta-blocker - C. LVEF 30%, NYHA II, sinus rhythm, resting HR 66 bpm on a beta-blocker - D. LVEF 55%, NYHA II, sinus rhythm, HR 80 bpm, on a beta-blocker - E. Acute decompensated HF in the emergency department, HR 110 bpm

Q4. A 58-year-old man starts dapagliflozin 10 mg daily for HFrEF. Which counselling point is most important? - A. Check blood sugar four times daily because he will become hypoglycemic - B. Stay hydrated; report dizziness on standing or genital itching or pain - C. Take it only on days when his legs look swollen or his weight is up - D. Double the dose when his weight rises - E. Skip it on days he drinks little fluid, and take two tablets the next day

Q5. A patient with HFrEF (LVEF 30%) has new atrial fibrillation with fast rates. Which drug is the most inappropriate choice for rate control? - A. Bisoprolol - B. Carvedilol - C. Metoprolol succinate - D. Digoxin - E. Diltiazem

Q6. Which patient should NOT receive vericiguat? - A. Hospitalized for worsening HF 3 weeks ago, now stable, SBP 112 - B. eGFR 40 mL/min/1.73 m2 - C. Taking digoxin - D. Taking riociguat for pulmonary hypertension - E. Taking a beta-blocker and an MRA

Q7. A patient with HF who weighs himself daily has gained 2.5 kg in 2 days and notes more ankle swelling. What advice is best? - A. Ignore it; small weight changes over two days are normal in heart failure - B. Stop all medications until the weight falls - C. Follow the action plan and contact the care team promptly - D. Drink extra fluids to flush the kidneys and lower the weight - E. Take an extra NSAID dose for the swelling and ankle pain

Q8. A 78-year-old with HFrEF, SBP 108 mmHg, takes enalapril 5 mg daily and is switching to sacubitril/valsartan. Which is best? - A. 97/103 mg BID started right away with no washout period - B. 49/51 mg BID immediately after stopping the enalapril today - C. Stop enalapril, wait 36 hours, start 24/26 mg BID - D. Continue the enalapril and add 24/26 mg BID on top of it - E. Wait 7 days after enalapril, then start 97/103 mg BID

Q9. A 28-year-old woman with HFrEF on ramipril, bisoprolol, spironolactone and dapagliflozin finds out she is pregnant. Which statement is best? - A. All four drugs are safe to continue until her first prenatal visit - B. Ramipril, spironolactone and dapagliflozin must not be used; contact the prescriber - C. Replace ramipril with sacubitril/valsartan, which is safe in pregnancy - D. Replace ramipril with candesartan, because candesartan is considered safe to use in pregnancy - E. Only bisoprolol needs to be stopped, and the other three can continue

Q10. A 70-year-old has symptomatic HF with LVEF 52% and raised NT-proBNP. According to the CCS/CHFS 2025 update, which two drug classes get a STRONG recommendation to reduce HF hospitalization? - A. ARNI and beta-blocker - B. ACEi and digoxin - C. Ivabradine and vericiguat - D. SGLT2 inhibitor and MRA - E. GLP-1 receptor agonist and loop diuretic

15. Answers and explanations

Q1. Answer D. 36 hours is the Health Canada washout because ACEi plus neprilysin inhibition raises angioedema risk ^{[S3; S2 p14]}. - A: no gap at all is dangerous (contraindicated together). B and C: too short. E: 7 days is longer than needed; the label says 36 hours. - Likely exam angle: washout times. Competency: safe drug use (Blueprint 1A).

Q2. Answer C. K above 5.4 mmol/L means consider decreasing or stopping the MRA; recheck labs ^{[S1 p8]}. - A: raising the dose raises K further. B: potassium supplements are to be avoided with MRAs ^[S9]. D: too late; risk of arrhythmia. E: triamterene is another potassium-sparing diuretic; the combination is dangerous (eplerenone is contraindicated with K-sparing diuretics ^[S10]). - Likely exam angle: lab thresholds.

Q3. Answer A. Health Canada: LVEF 35% or less, NYHA II-III, sinus rhythm, resting HR 77 or more, on standard therapy ^[S5]. - B: AF, not sinus rhythm. C: HR 66 is below the 77 bpm needed. D: LVEF 55% is outside the indication. E: acute/unstable HF is contraindicated.

Q4. Answer B. SGLT2 inhibitors act like a gentle diuretic, so volume depletion and dizziness can occur, and genital yeast infections are labelled warnings; counselling is to stay hydrated and report pain or redness in the genital area ^{[S7; S8]}. - A: SGLT2 inhibitors do not cause low blood sugar on their own, so four checks a day are not needed. C: it is a daily drug, not as-needed. D: the dose is fixed at 10 mg; never double. E: a double dose is never used, and holding the drug on a low-fluid day is not what the label says.

Q5. Answer E. Diltiazem is a non-dihydropyridine CCB that is harmful in HFrEF (US class 3 Harm, secondary sources ^{[U2; U3]}). No Canadian CCS or Health Canada statement for this was found in the sources used, so this is US-sourced and partly unconfirmed for Canada; also, the Canadian ivabradine label contraindicates diltiazem/verapamil with ivabradine ^[S5], and the Canadian dronedarone label bars dronedarone in HF ^[S15]. - A, B, C: evidence-based HF beta-blockers ^{[S2 p7]}. D: digoxin is an accepted add-on for AF with poor control ^{[S2 p13]}.

Q6. Answer D. sGC stimulators (riociguat) are contraindicated with vericiguat ^[S4]. - A: this is the intended population (recent decompensation, SBP at least 100). B: no dose change for renal function down to eGFR 15 in CCS notes. C: no interaction needing adjustment shown in the label. E: standard background therapy.

Q7. Answer C. More than 2 kg in 2 days is a warning sign; follow the plan and call the team ^{[S1 p13; S2 p6]}. - A: dangerous delay. B: stopping drugs can worsen HF. D: extra fluid adds to the load. E: NSAIDs worsen HF ^[U2].

Q8. Answer C. After ACEi, wait at least 36 hours; for age 75 or older, or SBP low, or low-dose ACEi, start 24/26 mg BID ^{[S3; S2 p14]}. - A and E: the target dose is too high at start. B: 49/51 mg is for patients on higher ACEi doses with no hypotension risk, and the washout is missing. D: ACEi plus ARNI together is contraindicated.

Q9. Answer B. The labels contraindicate or advise against these drugs in pregnancy (ACEi ^[S14], spironolactone ^[S9], dapagliflozin ^[S7]); the prescriber must change therapy urgently. - A: unsafe. C: sacubitril/valsartan is also contraindicated in pregnancy ^[S3]. D: drugs acting on the renin-angiotensin system, including valsartan in sacubitril/valsartan, cause fetal harm ^[S3]; the ACEi label gives the same warning for ACE inhibitors ^[S14]. No stand-alone ARB label was opened, so the candesartan statement rests on this class effect (stated in S3) and is partly unconfirmed. E: bisoprolol is not the main concern here; stopping it alone leaves the harmful drugs.

Q10. Answer D. CCS 2025: strong recommendations for SGLT2i and MRA in HF with LVEF above 40% ^{[S1 p4]}. - A, B: not in the HFnrEF tiers (ARNI is weak). C: these are HFrEF add-ons. E: GLP-1 RA is weak and only if BMI 30 or more with LVEF 45% or more; loop diuretics treat congestion only.

16. Sources

Tags used in the text. Accessed 2026-10-23. Canada first, then US.

Canada

• S1. CCS/CHFS 2025 Guideline Update for Pharmacologic Management of HF With Nonreduced EF (LVEF above 40%) - Pocket Guide. https://ccs.ca/wp-content/uploads/2026/04/CCS_Pocket_Guide_HFnrEF_ENG.pdf (pocket guide file dated April 2026; guideline Can J Cardiol 2025;41(10):1857-1874, Oct 2025).
• S2. CCS Heart Failure 2021 Pocket Guide (version HF-2021-03-P1, March 2021; copy hosted by the Government of Saskatchewan). https://publications.saskatchewan.ca/api/v1/products/129458/formats/155985/download. WARNING: 2021 content; the ccs.ca page for the 2021 update was not reachable (certificate error).
• S3. Entresto (sacubitril/valsartan) Product Monograph, Novartis Canada, authorized 2026-02-26 (Health Canada copy). https://pdf.hres.ca/dpd_pm/00083663.PDF
• S4. Verquvo (vericiguat) Product Monograph, Bayer Inc., dated April 27, 2023 on its cover (no later version found on the Health Canada site). https://pdf.hres.ca/dpd_pm/00070443.PDF
• S5. Lancora (ivabradine) Product Monograph, Servier Canada, date of authorization 2025-05-30. https://pdf.hres.ca/dpd_pm/00080705.PDF
• S6. Kerendia (finerenone) Product Monograph, Bayer Inc., 2026-01-19. https://pdf.hres.ca/dpd_pm/00083207.PDF
• S7. Forxiga (dapagliflozin) Product Monograph, revision Jan 22, 2025. https://pdf.hres.ca/dpd_pm/00078350.PDF
• S8. Jardiance (empagliflozin) Product Monograph, revision Jul 31, 2025. https://pdf.hres.ca/dpd_pm/00081256.PDF
• S9. Aldactone (spironolactone) Product Monograph, Pfizer, 2025-11-07. https://pdf.hres.ca/dpd_pm/00082356.PDF
• S10. Inspra (eplerenone) Product Monograph, BGP Pharma ULC (Viatris), last revised July 5, 2023. https://pdf.hres.ca/dpd_pm/00071512.PDF
• S11. pms-Carvedilol Product Monograph, revision Apr 4, 2022. https://pdf.hres.ca/dpd_pm/00065327.PDF
• S12. Apo-Bisoprolol Product Monograph, revision Apr 8, 2026. https://pdf.hres.ca/dpd_pm/00084194.PDF
• S13. pms-Digoxin Product Monograph, Pharmascience, revision Nov 23, 2022 (marketed; JAMP Digoxin, Dec 7, 2022, has the same points). https://pdf.hres.ca/dpd_pm/00069390.PDF
• S14. Teva-Ramipril Product Monograph, revision Oct 20, 2020. https://pdf.hres.ca/dpd_pm/00058445.PDF
• S15. Multaq (dronedarone) Product Monograph, revision Oct 1, 2024. https://pdf.hres.ca/dpd_pm/00077212.PDF
• S16. Teva-Pioglitazone Product Monograph, Teva Canada, Dec 12, 2025 (current marketed label). https://pdf.hres.ca/dpd_pm/00082763.PDF. The Actos brand monograph (Takeda, last revised Jan 18, 2018, https://pdf.hres.ca/dpd_pm/00043493.PDF) carries the same contraindication.
• S17. NACI Statement on pneumococcal vaccines in adults including Pneu-C-21, Nov 15, 2024. https://www.canada.ca/en/public-health/services/publications/vaccines-immunization/national-advisory-committee-immunization-statement-recommendations-use-pneumococcal-vaccines-adults-pneu-c-21.html
• S18. NACI summary of the statement on seasonal influenza vaccines for 2025-2026 (April 30, 2025). https://www.canada.ca/en/public-health/services/publications/vaccines-immunization/national-advisory-committee-immunization-summary-seasonal-influenza-vaccines-2025-2026.html. A 2026-2027 NACI summary exists (CCDR, September 2026; https://publications.gc.ca/collections/collection_2026/aspc-phac/HP3-1-52-9-eng.pdf) but could not be read; check it.
• S19. Virani SS, et al. Canadian Cardiovascular Society/Canadian Heart Failure Society 2025 Guideline Update for Pharmacologic Management of Heart Failure With Nonreduced Ejection Fraction (LVEF > 40%). Can J Cardiol 2025;41(10):1857-1874. doi 10.1016/j.cjca.2025.07.027. Two author corrections were published in Can J Cardiol in September 2026 (doi 10.1016/j.cjca.2025.12.030 and 10.1016/j.cjca.2026.03.026); what they changed could not be read.

United States

• U1. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. Circulation 2022;145:e895-e1032, https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 (full text could not be opened here; JACC 2022;79:e263-e421, https://doi.org/10.1016/j.jacc.2021.12.012). Summary used: ACC 'Key Perspectives' (Mar 2022), https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2022/03/29/19/53/2022-aha-acc-hfsa-heart-failure-guideline-gl-hf. Newer US document: 2026 ACC Expert Consensus Decision Pathway for HFpEF, J Am Coll Cardiol 2026;88:1817-1846, https://doi.org/10.1016/j.jacc.2026.06.018 (read only through summaries).
• U2. Guideline Central excerpt of the 2022 AHA/ACC/HFSA guideline (NSAIDs class 3 Harm, B-NR) and a CardioNerds summary for NDHP-CCB/TZD harm, seen through search extracts. https://eguideline.guidelinecentral.com/i/1461930/26 (secondary).
• U3. Pharmacy Times, "Clinical overview: potentially harmful medications in heart failure" (secondary; date not read). https://pharmacytimes.com/view/clinical-overview-potentially-harmful-medications-in-heart-failure
• U4. DailyMed, Entresto US label (revised 4/2024). https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=000dc81d-ab91-450c-8eae-8eb74e72296f
• U5. Bayer / Business Wire, FDA approval of Kerendia for HF with LVEF 40% or more, July 2025 (news release, secondary to the FDA label). https://www.businesswire.com/news/home/20250713516485/en/U.S.-FDA-Approves-KERENDIA-finerenone-to-Treat-Patients-With-Heart-Failure-With-Left-Ventricular-Ejection-Fraction-40-Following-Priority-Review
• U6. ACC "Poll results: sodium restriction in patients with HFrEF" (Nov 2022; quoting the 2022 guideline class 2a, C-LD recommendation). https://www.acc.org/latest-in-cardiology/articles/2022/11/15/18/11/poll-results-sodium-restriction-in-patients-with-hf
• U7. Secondary summaries of ACC/AHA stages A-D (AJMC, nursing center summary). https://www.ajmc.com/view/new-hf-definition-stage-updates-outlined-in-2022-acc-aha-hfsa-guidelines
• U8. NYHA classes, FPnotebook (secondary; wording matches other pages seen). https://fpnotebook.com/CV/Exam/NyhHrtFlrClsfctn.htm

Sources not available and what was used instead

• Primary 2022 AHA/ACC/HFSA guideline (AHA Journals, JACC) - access blocked (HTTP 403). Used the ACC key points page, Guideline Central excerpts, ACC poll article and Pharmacy Times instead (secondary).
• AHA "Classes of heart failure" page and a PMC NYHA table - blocked (403 / captcha). Used FPnotebook for NYHA wording.
• CCS web pages (ccs.ca guideline pages) - HTTPS certificate error in the fetch tool; the pocket guide PDFs were downloaded instead.
• Full text of CCS/CHFS 2025 article (onlinecjc.ca) - not opened; used the CCS pocket guide.
• Brand monographs for Lanoxin, Monocor and Lasix had no PDF link in the Drug Product Database; used the PMS-Digoxin, Apo-Bisoprolol PMs and the CCS table instead. No Health Canada furosemide label was read.
• Heart Failure Canada resources, Hypertension Canada and Thrombosis Canada pages - not opened; not used.
• CCS 2017 comprehensive HF guidelines - not opened.

17. Unconfirmed / check yourself

• The two September 2026 author corrections to the CCS/CHFS 2025 guideline (HF with non-reduced EF) could not be read; check what they changed before the exam.

• Primary US sources (2022 AHA/ACC/HFSA guideline, 2026 ACC HFpEF pathway) could not be opened here; US points rest on summaries.

• Typical precipitants (missed pills, infection, arrhythmia, dietary salt) - general teaching, not confirmed in the sources used.

• Exact primary-text wording for ACC/AHA stages A-D, NYHA definitions, and US class labels for NDHP-CCB, TZD and other "avoid" drugs (secondary sources only).
• Nebivolol in HF - not in the CCS table; not verified.
• Metoprolol succinate availability in Canada - not verified (brand search of the Drug Product Database found no match; do not teach it as a Canadian product without checking).
• Iron deficiency treatment in HF (IV iron): ferritin is in the work-up list, but treatment wording was not confirmed.
• Amiodarone/dofetilide use in HF, trimethoprim and other hyperkalemia interactions beyond those listed on the labels, beta-blocker use with asthma/COPD in HF, sleep apnea/anemia/depression screening, Thrombosis Canada advice for AF with HF.
• The CCS 2021 guide is still the latest CCS HFrEF guideline (checked October 2026). The CCS table prints the start dose as "12.2-25 mg" (probably 12.5).
• Canagliflozin HF indication in Canada - not verified.
• Oral doses of loop diuretics (furosemide, torsemide, bumetanide) and thiazide start doses.
• Explicit CCS monitoring schedule for ACEi/ARB (labs at about 1 week) - only given for MRA and ARNI.
• Fluid restriction advice for chronic HF; alcohol limits; sick-day rules for SGLT2i wording.
• Emergency hyperkalemia treatment; PPCM treatment; vaccine recommendations beyond influenza and pneumococcal.
• Vericiguat US status.
• CCS referral timeline page text was scrambled in extraction; the times need checking on the original.
• Whether sacubitril/valsartan has a Health Canada indication for LVEF above 40% (only HFrEF NYHA II-III was found).

Study aid, not medical advice. Check official sources before any patient decision.

MapleRxPrep

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