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● Diuretics should be given only at symptoms of fluid retention (edema, weight increase), with loop diuretics prescribed only if thiazide diuretics are insufficient.
● In contrast, all patients should be treated continuously with an angiotensin converting enzyme inhibitor (if not tolerated replace with an angiotensin receptor blocker) in combination with one of the clinically-proven beta blockers (bisoprolol, metoprolol succinate, carvedilol, or nebivolol).
● Patients remaining symptomatic despite this treatment should additionally receive a mineralocorticoid receptor antagonist.
● If this triple therapy is insufficient, you should consider ivabradine in patients in sinus rhythm with heart rate >70 b.p.m. and EF <35%. (Note that ivabradine may be also considered for patients in sinus rhythm with an EF <35% and a heart rate >70 b.p.m. intolerant of beta-blockers.)
● Low-dose digitalis glycosides may be considered for patients with EF <45% who remain symptomatic despite treatment with an angiotensin converting enzyme inhibitor, beta blocker, and a mineralocorticoid receptor antagonist.
● Note that pharmacotherapy of chronic heart failure is increasingly supplemented by interventional approaches such as cardiac resynchronisation therapy and biventricular pacing.
Guidelines of cardiovascular disease  Addenda 2012