Heart Failure Treatment Protocol: Thailand’s 2025 Step-by-Step Guide

1 | Classify the Patient

1. Echo first – confirm EF.
2. Assign phenotype • HFrEF ≤ 40 % • HFmrEF 41–49 % • HFpEF ≥ 50 % • HFimpEF (normalised after treatment – stay on full therapy).
3. Stage decompensation – “dry/wet” (congestion) and “warm/cold” (perfusion).
4. Screen triggers – ischaemia, arrhythmia, infection, diet lapse, drug non‑adherence.

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2 | Immediate OPD Start‑Up (diagnosis day 0)

Aim to launch all four pillars within 4 weeks.

Step 1 – Neurohormonal blockade

• If SBP > 110 mmHg and no ACEi allergy: start sacubitril/valsartan 24/26 mg BID (E2 list; begin NHSO/CSMBS paperwork the same day).
• If SBP is low or ARNI is unaffordable now: start enalapril 2.5 mg BID, plan to switch to ARNI after 2 weeks.

Step 2 – β‑blocker

• Carvedilol 3.125 mg BID (on NLEM).
• Start only when euvolaemic; double every 2 weeks if HR > 60 bpm and SBP ≥ 100 mmHg.

Step 3 – Mineralocorticoid receptor antagonist

• Spironolactone 12.5–25 mg OD (cost < 1 THB).
• Check K⁺ and creatinine within 3–7 days.

Step 4 – SGLT2 inhibitor

• Dapagliflozin or empagliflozin 10 mg OD once eGFR ≥ 30.
• Reduce loop‑diuretic dose if weight is steady.

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3 | Add‑Ons for Persistent Symptoms or Specific Profiles

• Loop diuretic titrate by daily weight log; IV route if OPD failure.
• Hydralazine + isosorbide dinitrate for Black/Asian NYHA III–IV or RAAS‑intolerant; generic combo tablets widely available.
• Ivabradine if sinus rhythm HR ≥ 70 bpm despite max β‑blocker.
• IV iron (iron sucrose) for ferritin < 100 µg/L or TSAT < 20 %.
• Vericiguat and omecamtiv only via trial/compassionate channels in Thailand.

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4 | Thirty‑Day Titration Roadmap

• Day 0 – Echo, BNP, start β‑blocker + ACEi/ARNI, give loop IV/PO as needed.
• Day 7 – Add spironolactone; switch ACEi→ARNI if paperwork cleared; add SGLT2i if euvolaemic.
• Day 14 – Up‑titrate β‑blocker and ARNI; reassess weight, BP, renal profile.
• Day 28 – Repeat labs, adjust doses toward targets, screen for ICD/CRT eligibility (EF ≤ 35 %, LBBB ≥ 150 ms).

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5 | Indications for Inpatient Admission

• Rest dyspnoea or pulmonary oedema unresponsive to OPD diuretic.
• New hypoxaemia, SpO₂ < 90 % on room air.
• Hypotension (SBP < 90 mmHg) with cool extremities, oliguria, or confusion.
• Rapid AF, VT, VF, syncope.
• Acute coronary syndrome, myocarditis, massive PE.
• Worsening renal function or uncontrolled hyper‑/hypokalaemia.

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6 | In‑Hospital Decompensation Protocol

1. Airway/Breathing – oxygen; NIV (CPAP/BiPAP) if severe dyspnoea.
2. Circulation • IV furosemide 40 mg bolus (or 1–2 × home dose).• Add thiazide (oral metolazone) if diuretic resistance. • IV GTN infusion when SBP > 100 mmHg, especially for flash pulmonary oedema. • IV dobutamine or milrinone only for cardiogenic shock.
3. Search and treat precipitant – ECG, troponin, CXR, cultures, TSH, etc.
4. Restart or initiate GDMT before discharge – begin ARNI, SGLT2i during stay if BP and renal function allow.
5. Discharge checklist – euvolaemic, weight stable 48 h, home meds supplied, follow‑up < 7 days, patient taught red‑flag signs.

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7 | HFmrEF Approach

• Apply full quadruple therapy exactly as HFrEF.
• Expect similar benefit if tolerated.
• Treat dominant trigger (ischaemia, HTN, tachyarrhythmia).
• Monitor EF: may drift to HFrEF or improve to HFimpEF; therapy continues regardless.

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8 | HFpEF Strategy

Disease‑modifying anchor

• SGLT2 inhibitor 10 mg OD (start inpatient if admitted).

Symptom and comorbidity control

• Loop diuretic for congestion (avoid over‑diuresis).
• Tight blood‑pressure aim 120–130/80 using amlodipine, ACEi, ARB.
• Trial spironolactone if EF in low‑50s or BNP elevated.
• Consider sacubitril/valsartan for EF 45–50 % with uncontrolled symptoms or HTN.
• Manage AF aggressively (rate or rhythm control; ablation under CSMBS).
• Weight reduction if BMI > 27.5; address OSA.
• Screen for infiltrative disease; give tafamidis for confirmed TTR amyloidosis.

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9 | Device and Advanced Therapy Pathway

• ICD – EF ≤ 35 %, NYHA II–III, ≥3 months GDMT. Initiate e‑referral; limited public slots—early application critical.
• CRT – EF ≤ 35 % plus LBBB ≥ 150 ms (or non‑LBBB ≥ 150 ms with strong symptoms).
• MitraClip – severe secondary MR with persistent symptoms despite GDMT; available in select centres.
• CardioMEMS – NYHA III with recent admission; self‑funded currently.
• LVAD / Transplant – stage D; refer via cardiology fast‑track to Bangkok transplant hubs.
• Palliative care – introduce when goals shift from life‑prolonging to comfort; home inotropes possible.

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10 | Long‑Term Surveillance and Patient Empowerment

• Labs – check K⁺/Cr 7 days after starting or up‑titrating ARNI, MRA; then every 3–6 months.
• Vaccination – yearly influenza, pneumococcal at 65 y, COVID boosters.
• Daily weight log – share via LINE chat for remote titration; alert if +2 kg in 3 days.
• Salt intake – < 2 g/day; provide Thai‑language handout listing high‑salt street foods.
• Exercise – enrol in cardiac rehab or prescribe home walking 30 min ≥ 5x/week.
• Medication adherence – pill organisers; nurse phone follow‑up in week 1, month 1, every 3 months thereafter.
• Don’t stop GDMT – reinforce that EF improvement does not mean cure; withdrawal triples relapse risk.

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11 | Key Messages

1. Start ARNI and SGLT2i early; paperwork can run in parallel.
2. Affordability is not fatal – carvedilol plus spironolactone cost < 4 THB/day and save lives.
3. Refer for CRT/ICD as soon as criteria met – queues are long; earlier referral prevents sudden death.
4. Virtual HF clinics and nurse‑led titration cut 30‑day readmissions by one‑third.
5. Escalate or de‑escalate loop diuretic by weight trend, not by fixed dose.
6. Screen and treat iron deficiency, sleep apnoea, obesity, depression – outcomes hinge on whole‑patient care.

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Conclusion

Implementing this ordered, evidence‑aligned pathway—classification, rapid quadruple therapy, tailored inpatient protocols, aggressive follow‑up, and early device referral—wins the survival gains shown in global trials while respecting Thailand’s formulary, budget, and referral realities. Adopt it as a living protocol, review quarterly, and keep every team member from village clinic to transplant centre on the same page.

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Quick‑Order Drug Summary for Heart‑Failure Patients (Thailand, 2025)

How to use the table

1. Identify phenotype → go straight to ARNI + β‑blocker + MRA + SGLT2i rows and launch quickly.
2. Check blood pressure & kidney function before each escalation.
3. Layer add‑ons (loop, ivabradine, etc.) only if symptoms persist or special indications apply.
4. Use the Thai access column to anticipate paperwork or counselling on out‑of‑pocket costs.

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One‑Page Quadruple‑Therapy Cheat Sheet (HFrEF ≤ 40 %)

How to use it

1. Launch ARNI ± β‑blocker on Day 0 (ARNI first if BP allows).
2. Add MRA a week later once labs confirm safety.
3. Insert SGLT2i anytime—sooner if stable, later if still “wet.”
4. Up‑titrate every 2 weeks toward targets, checking labs as shown.
5. Keep all four on board for life, even after EF improves.