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Heart failure

Description

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

Alternative Names

Cardiomyopathy; Congestive heart failure

Treatment

Recent expert guidelines for evaluating the severity of heart failure and determining treatments use a staging system that is similar to the one used for major cancers:

• Stage A : Patients are at high risk for heart failure, but there is no evidence of structural damage to the heart. 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).
• Stage B : Patients have a structural heart abnormality but no symptoms of heart failure. Abnormalities include left ventricular hypertrophy and low ejection fraction, asymptomatic valvular heart disease, and a previous heart attack.
• Stage C : Patients have a structural abnormality and current or previous symptoms of heart failure, including shortness of breath, fatigue, and difficulty exercising.
• Stage D : Patients have end-stage symptoms that do not respond to standard treatments.

Treatment for Stage A Heart Failure

According to expert guidelines, the first step in managing heart failure is to treat the primary conditions causing or complicating heart failure. These 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 below 80 mm Hg. Patients with diabetes 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 information on treatments, see In-Depth Report #60: Diabetes - type 2 and In-Depth Report #9: Diabetes - type 1.]
• 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. Giving erythropoietin (EPO) and iron injections to patients with heart failure and underlying anemia not only reverses the anemia, but may markedly improve heart symptoms as well. [For more information, see In-Depth Report #57: Anemia.]
• Thyroid function . Various medications are used to treat overactive thyroid (hyperthyroidism) or underactive thyroid (hypothyroidism).
• Sleep apnea . Continuous positive airway pressure (CPAP) is an effective treatment for sleep apnea. CPAP may help reduce systolic blood pressure and improve left ventricular systolic function. [For more information, see In-Depth Report #65: Sleep apnea.]

Treatment for Stage B

Treatments for patients with Stage B risk for heart failure include all of the treatments recommended in Stage A. In addition, the following types of drugs and devices may be recommended for some patients. These include:

• Angiotensin-converting enzyme (ACE) inhibitors for patients with a recent or past history of heart attack. Also for patients who have not had a heart attack if they have a low left ventricular ejection fraction (LVEF) and no heart failure symptoms. A reduced LVEF indicates that the heart’s left ventricle is not pumping blood efficiently.
• 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 without heart failure symptoms.
• Angiotensin-receptor blockers (ARBs) for patients who have had a heart attack or have low LVEF, but who cannot take ACE inhibitors.
• Implantable defibrillators for patients who have weakened heart pumps (ischemic cardiomyopathy), who had a heart attack more than 40 days prior, and who have low LVEF.

Treatment for Stage C

Treat conditions as recommended in Stage A plus:

• Restrict dietary salt. Lowering salt in the diet can help diuretics work better.
• ACE inhibitors, beta blockers, and diuretics are recommended for most patients.
• ARBs are recommended for patients who cannot tolerate ACE inhibitors.
• Aldosterone inhibitors or digitalis may be used for some patients.
• A hydralazine and nitrate combination (BiDil) may be used for African American patients who are taking an ACE inhibitor and beta blocker and who still have heart failure symptoms.
• Avoid drugs that can worsen heart failure symptoms. These include nonsteroidal anti-inflammatory drugs (NSAIDs), most calcium channel blockers, and most drugs used to treat irregular heart rhythms (arrhythmia).
• Exercise training for appropriate patients.
• Biventricular pacemakers and implantable defibrillators for some patients.

Treatment for Stage D

Treatment includes appropriate measures used for Stages A, B, and C plus:

• 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.

• Review Date: 4/11/2006
• Reviewed By: Harvey Simon, M.D., Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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