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Heart failure - Treatment

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of heart failure.

Alternative Names

Cardiomyopathy; Congestive heart failure

Treatment:

Heart failure is classified into four stages (Stage A through Stage D) that reflect the development and progression of the condition. Treatment depends on the stage of heart failure.

The first two stages (Stage A and Stage B) are technically not heart failure, but indicate that a patient is at high risk for developing it.

Management of Risk Factors and Causes

Stage A. In Stage A, patients are at high risk for heart failure but do not show any symptoms or have structural damage of the heart. The first step in managing or preventing heart failure is to treat the primary conditions that cause or complicate heart failure. Risk factors include high blood pressure, heart diseases, diabetes, obesity, metabolic syndrome, and previous use of medications that damage the heart (such as some chemotherapy).

Important risk factors to manage include:

  • Coronary artery disease. Treatment includes a healthy diet, exercise, smoking cessation, medications, and, possibly, bypass or angioplasty. [For more information, see In-Depth Report #3: Coronary artery disease and angina.]
  • Cholesterol and lipid problems. Treatments include lifestyle management and medications, especially statins. [For more information, see In-Depth Report #23: Cholesterol.]
  • High blood pressure. A normal systolic blood pressure is considered below 120 mm Hg, and a normal diastolic blood pressure is below 80 mm Hg. Patients with diabetes, atherosclerosis, or chronic kidney disease should maintain blood pressure readings of 130/80 or less, while other patients with high blood pressure should aim for readings no higher than 140/90. Effective reduction of blood pressure reduces the risk of heart failure by 30 - 50%. [For more information, see In-Depth Report #14: High blood pressure.]
  • Diabetes. Treating diabetes is extremely important for reducing the risk for heart disease. ACE inhibitors are especially beneficial, particularly for people with diabetes. Recent research suggests that metformin, a drug used to treat diabetes, may also help prevent heart failure. [For more information, see In-Depth Report #60: Diabetes - type 2; and In-Depth Report #9: Diabetes - type 1 ]
  • Obesity. [For more information, see In-Depth Report #53: Weight control and diet ]
  • Valvular abnormalities, such as aortic stenosis and mitral regurgitation. Surgery may be required.
  • Abnormal health rhythms (arrhythmias). Ventricular assisted devices, notably biventricular pacers (BVPs), are proving to be important in preventing hospitalizations for patients with these conditions.
  • Anemia. Patients with heart failure and underlying anemia should have their anemia corrected. On occasion, this may require erythropoiesis-stimulating drugs.. [For more information, see In-Depth Report #57: Anemia.]
  • Thyroid function. Various medications are used to treat overactive thyroid (hyperthyroidism) or underactive thyroid (hypothyroidism). [For more information, see In-Depth Report #38: Hypothyroidism.]
  • Drugs. Avoid drugs that can worsen heart failure symptoms. Talk with your doctor about your heart failure before taking nonsteroidal anti-inflammatory drugs (NSAIDs), calcium channel blockers (verapamil and diltiazem), thiazolidinediones (drugs used for diabetes), antitumor necrosis factors, and most drugs used to treat irregular heart rhythms (arrhythmia).
  • Diet. It is particularly important to reduce sodium (salt) intake to less than 1,500 mg a day.
  • Exercise. Patients should engage in medically supervised exercise programs.

Treatment Based on Heart Failure

Stage B. Patients have a structural heart abnormality seen on echorcardiogram or other imaging tests but no symptoms of heart failure. Abnormalities include left ventricular hypertrophy and low ejection fraction, asymptomatic valvular heart disease, and a previous heart attack. In addition to the treatment guidelines for Stage A, the following types of drugs and devices may be recommended for some patients:

  • Angiotensin-converting enzyme (ACE) inhibitors, or angiotensin-receptor blockers (ARBs) for patients who cannot tolerate ACE inhibitors.
  • Beta blockers for patients with a recent or past history of heart attack. Also for patients who have not had a heart attack but who do have reduced LVEF identified in diagnostic tests.

Stage C. Patients have a structural abnormality and current or previous symptoms of heart failure, including shortness of breath, fatigue, and difficulty exercising. Treatment includes those for Stage A and B plus:

  • Restrict dietary salt. Lowering salt in the diet can help diuretics work better.
  • ACE inhibitors or angiotensin-receptor blockers (ARBs).
  • Beta blockers (bisoprolol, carvedilol, and sustained release metoprolol).
  • Diuretics are recommended for most patients, with loop diuretics such as furosemide generally being the first-line choice.
  • Aldosterone inhibitors or digitalis may be used for some patients.
  • A hydralazine and nitrate combination (BiDil) should be used for African-American patients who are taking an ACE inhibitor, beta blocker, and diuretic and who still have heart failure symptoms.
  • Exercise training for appropriate patients.
  • Implantable cardiac defibrillators (ICDs) may be considered for patients with very low ejection fraction or those who have had dangerous arrhythmias.
  • Cardiac resynchronization therapy (pacemaker), with or without ICD, for some patients.

Stage D. Patients have end-stage symptoms that do not respond to standard treatments. Treatment includes appropriate measures used for Stages A, B, and C plus:

  • Strict control of fluid retention.
  • Heart transplantation referral for appropriate patients.
  • Left-ventricular assist devices (LVADs) as permanent therapy for patients who are not candidates for heart transplants. LVADs are surgically implanted to help pump blood through the body.
  • Hospice and end-of-life care information for patients and families.

Management of Precipitating Factors

Whenever heart failure worsens, whether quickly or chronically over time, various factors must be considered as the cause:

  • Dietary indiscretion. Sometimes as little as eating a sausage or some sauerkraut with extremely high sodium content is enough to precipitate an acute episode. Otherwise, compliance with any fluid and salt restrictions must be considered.
  • Alcohol. Depending on the severity of a patient's heart failure, one or more drinks may suddenly worsen symptoms.
  • Medication compliance. Patients may forget or purposely skip a medication, or may not be able to afford or have access to medications.
  • Angina or heart attack. Worsening of coronary artery disease may make the heart muscle less able to pump enough blood.
  • Arrhythmias. Increases in the heart rate, or a slowing of the heart rate below normal, may also affect the ability of the heart to function. Likewise, an irregular heart rhythm such as atrial fibrillation may cause a flareup.
  • Anemia. It is unclear whether anemia causes heart failure or is a symptom of heart failure. Most anemias may be treated with iron replacement therapy. A more significant anemia can cause a worsening of heart failure and should be treated promptly.

Resources

References

Bibbins-Domingo K, Pletcher MJ, Lin F, Vittinghoff E, Gardin JM, et al. Racial differences in incident heart failure among young adults. N Engl J Med. 2009 Mar 19;360(12):1179-90.

Birks EJ, Tansley PD, Hardy J, George RS, Bowles CT, Burke M, et al. Left ventricular assist device and drug therapy for the reversal of heart failure. N Engl J Med. 2006 Nov 2;355(18):1873-84.

Carlson MD, Wilkoff BL, Maisel WH, Carlson MD, Ellenbogen KA, Saxon LA, et al. Recommendations from the Heart Rhythm Society Task Force on Device Performance Policies and Guidelines Endorsed by the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) and the International Coalition of Pacing and Electrophysiology Organizations (COPE). Heart Rhythm. 2006 Oct;3(10):1250-73.

Epstein AE, Dimarco JP, Ellenbogen KA, Estes NA 3rd, Freedman RA, Gettes LS, et al. ACC/AHA/HRS 2008 Guidelines for device-based therapy of cardiac rhythm abnormalities. Heart Rhythm. 2008 Jun;5(6):e1-62. Epub 2008 May 21.

Gissi-HF Investigators, Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG, et al. Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. Lancet. 2008 Oct 4;372(9645):1223-30. Epub 2008 Aug 29.

Hare JM. The dilated, restrictive, and infiltrative cardiomyopathies. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders; 2007: chap 64.

Haykowsky MJ, Liang Y, Pechter D, Jones LW, McAlister FA, Clark AM. A meta-analysis of the effect of exercise training on left ventricular remodeling in heart failure patients: the benefit depends on the type of training performed. J Am Coll Cardiol. 2007 Jun 19;49(24):2329-36. Epub 2007 Jun 4.

Hess OM and Carroll JD. Clinical assessment of heart failure. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders; 2007: chap 23.

Hildebrandt P. Systolic and nonsystolic heart failure: equally serious threats. JAMA. 2006 Nov 8;296(18):2259-60.

Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG, et al. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009 Apr 14;119(14):1977-2016. Epub 2009 Mar 26

Konstam MA, Gheorghiade M, Burnett JC Jr, Grinfeld L, Maggioni AP, Swedberg K, et al. Effects of oral tolvaptan in patients hospitalized for worsening heart failure: the EVEREST Outcome Trial. JAMA. 2007 Mar 25; [Epub ahead of print]

Khush KK, Waters DD, Bittner V, Deedwania PC, Kastelein JJ, Lewis SJ, et al. Effect of high-dose atorvastatin on hospitalizations for heart failure: subgroup analysis of the Treating to New Targets (TNT) study. Circulation. 2007 Feb 6;115(5):576-83. Epub 2007 Jan 29.

Liu PP and Schultheiss H-P. Myocarditis. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders; 2007: chap 66.

Mann DL. Management of heart failure patients with reduced ejection fraction. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders; 2007: chap 25.

McAlister FA, Ezekowitz J, Dryden DM, Hooton N, Vandermeer B, Friesen C, et al. Cardiac Resynchronization Therapy and Implantable Cardiac Defibrillators in Left Ventricular Systolic Dysfunction. Evidence Report/Technology Assessment No. 152 (Prepared by the University of Alberta Evidence-based Practice Center under Contract No. 290-02-0023). AHRQ Publication No. 07-E009. Rockville, MD: Agency for Healthcare Research and Quality. June 2007.

Naka Y and Rose EA. Assisted circulation in the Treatment of Heart Failure. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders; 2007; chap 28.

Rich S and McLaughlin VV. Pulmonary hypertension. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders; 2007: chap 73.

Schocken DD, Benjamin EJ, Fonarow GC, Krumholz HM, Levy D, Mensah GA, et al.Prevention of heart failure: a scientific statement from the American Heart Association Councils on Epidemiology and Prevention, Clinical Cardiology, Cardiovascular Nursing, and High Blood Pressure Research; Quality of Care and Outcomes Research Interdisciplinary Working Group; and Functional Genomics and Translational Biology Interdisciplinary Working Group. Circulation. 2008 May 13;117(19):2544-65. Epub 2008 Apr 7.

  • Reviewed last on: 5/13/2009
  • Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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