Table 3:

Practical considerations for maximal medical therapy in heart failure

Concern	Solution
Clinical time constraints	Multidisciplinary heart failure disease management program Nurse- or pharmacy-directed medication titration clinic Nurse-directed titration schedule via phone
Low blood pressure to add new medications	Decrease unnecessary blood pressure lowering medications not known to benefit heart failure outcomes Space out medications throughout day Assess for hypovolemia
Orthostatic symptoms	Decrease diuretics Space out medications throughout day Counsel on behavior modification (e.g., standing slowly, etc.)
Low enough blood pressure/heart rate to titrate medications	Ensure appropriate blood pressure and heart rate targets Track patient’s symptoms rather than absolute hemodynamic numbers
Fatigue	Move beta-blocker dosing to nighttime Counsel on importance of medication and need to “power through” potentially manageable symptoms