This handout is for acute hf — frail elderly (age ≥80, cfs ≥6). Your care team identified this based on: age ≥80 + adhf presentation → frail-hf screen + geriatric-aware management.
Other reasons your team may use this plan: clinical frailty scale (rockwood) ≥6 (moderately frail) at baseline → frail hf pathway; fried frailty phenotype ≥3 of 5 (weight loss, exhaustion, weakness, slow gait, low activity) → frail hf pathway; ≥10 chronic medications + adhf → stoppfrail medication review trigger.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| furosemide | IV 1-1.5× home dose (NOT 2-2.5×); if naïve start 20-40 mg IV (NOT 80 mg); reassess UOP at 4h (NOT 2h) | IV | q8-12h titrate | DOSE PMID 21366472 — high-dose IV loop NOT validated in frail elderly; gentler dosing avoids AKI + electrolyte disturbances + falls + delirium; tolerate slower decongestion to preserve renal function |
| carvedilol | 1.5625 mg PO BID (1/2 of standard 3.125 starter); titrate q4 weeks NOT q2 weeks; target may be 6.25 BID NOT 25 BID | PO | BID | SENIORS PMID 15642706 — BB benefit in elderly preserved but tolerability requires lower starting + slower titration; CSANZ HFSA 2024 frail HF position; STRONG-HF subgroup PMID 36356631 |
| sacubitril-valsartan | 12/13 mg PO BID (1/2 of standard 24/26 starter); titrate q4 wk if SBP ≥110 + Cr stable + K <5.0 | PO | BID | PIONEER-HF PMID 30403955 elderly subgroup — ARNI benefit preserved; lower starting dose mitigates orthostatic hypotension risk; HOLD if symptomatic orthostasis |
| empagliflozin | 10 mg PO daily — full standard dose (NO renal-elderly dose adjustment unless eGFR <20) | PO | daily | EMPULSE PMID 35347356 + DELIVER PMID 36027564 elderly subgroup — well-tolerated; preserved benefit with same-dose; monitor for euvolemia (mild diuretic effect) |
| spironolactone | 12.5 mg PO every other day (NOT daily 25 mg) if eGFR 30-45; 12.5 mg daily if eGFR ≥45; HOLD if eGFR <30 | PO | every other day or daily | EMPHASIS-HF elderly subgroup — benefit preserved but hyperK risk doubled; ultra-low starter + every-other-day dosing if borderline renal; check K + Cr at week 1 then q2 wk |
| midodrine | 2.5 mg PO TID titrate to 5-10 mg TID; last dose by 4 PM (avoid supine HTN at night) | PO | TID | Permits GDMT up-titration in patients with orthostasis-limited regimen; do NOT use if supine HTN; common useful adjunct in frail HF per CSANZ HFSA 2024 |
| apixaban | 2.5 mg PO BID (dose-reduction criteria: age ≥80 + Cr ≥1.5 + weight ≤60 kg = 2 of 3); standard 5 mg BID if not meeting reduction criteria | PO | BID | ARISTOTLE elderly subgroup — apixaban preferred over warfarin in frail elderly (lower bleeding); auto dose-reduction in elderly per label |
Plan: Frail-elderly ADHF — gentler decongestion + 25% GDMT + deprescribing per STOPPFrail (ACC/AHA 2022 §11; Khan 2020; CSANZ HFSA 2024)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
STRONG-HF SLOW cadence (q4 wk not q2 wk titration in CFS ≥6 per Mebazaa subgroup); 1-wk PCP visit + 2-wk HF clinic (in-home if homebound); home-health PT for fall prevention; medication reconciliation at every visit; advance directives finalized
Guideline: 2022 ACC/AHA HF §11 geriatrics + 2024 CSANZ HFSA frail-HF position + STOPPFrail (Lavan 2017)