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Treatment of heart failure

The management of heart failure depends on its cause and clinical course, therefore an individualized approach to the treatment is mandatory. Diuretics and angiotensin converting enzyme (ACE) inhibitors, when combined with nonpharmacological measures, remain the basis of treatment in patients with heart failure.

Non pharmacological management

Various nonpharmacological measures to improve symptoms and prognosis of heart failure include the following:8
  • Aregularly scheduled exercise program, for selected patients.

  • Weight reduction and weight monitoring.

  • Sodium restriction.

  • Fluid restriction, limited to 1.5 L daily.

  • Avoidanceof nonsteroidal antiinflammatory drugs (NSAIDs).

  • Abstain from or limit alcohol consumption.

Revascularization and surgical therapy

As CAD is the primary etiology in two-thirdsof all cases of heart failure, practice guidelines and recent studies recommendcoronary revascularization for patients with heart failure and CAD.9 Patients with severe CAD and symptomatic left ventricular systolic dysfunction had been observed to have poor outcomes, when treated medically, despite the advances in medical therapy over the past decade.

Revascularization either by coronary artery bypass graft surgery or by percutaneous coronary intervention may improve the long-term outcomes in patients with left ventricular dysfunction and myocardial ischemia, and reduces the risk of sudden death.10

Pharmacological management of heart failure

The pharmacologic treatment tackles four specific management goals:

  • Optimization of the treatment of etiologic conditions.

  • Treatment of fluid retention symptoms.

  • Prevention of disease progression.

  • Delay in mortality.

The following pharmacological agents are used:

For symptomatic improvement:

  • Diuretics — furosemide, thiazide and spironolactone

  • ACE inhibitors — enalapril, lisinopril and perindopril

  • Angiotensin receptor blockers (ARBs) — losartan and candesartan

  • Positive inotropes — digoxin

For improvement in survival

  • ACE inhibitors

  • Beta blockers — carvedilol, metoprolol and atenolol

  • Vasodilators — oral nitrates in combination with hydralazine

Diuretic therapy is indicated for relief of congestive symptoms. The ACE inhibitors, when added to diuretics, improve the symptoms, exercise tolerance and reduce hospital admission rates in chronic heart failure. The primary action of beta-blockers is to counteract the unfavorable effectsof the sympathetic nervous system that are activated during heart failure. The beneficial effects of beta-blockers include improvement in the heart remodeling and ejection fraction, the rate of hospitalization, survival, quality of life and the incidence of sudden death.1

The ARBs should be used only in patients who can not tolerate ACE inhibitors because of severe cough or angioedema (rapid swelling of the skin, mucosa and submucosal tissues). In patients who remain symptomatic despite diuretic and beta-blocker therapy, treatment with the vasodilator combination of hydralazine and isosorbide dinitrate may be an alternative.1 Once used as first-line therapy, digoxin is now reserved for the control of ventricular rhythm in patients with atrial fibrillation or where adequate control is not achieved with an ACE inhibitor, beta-blocker or a diuretic.

Written by: healthplus24.com team
Date last updated: September 22, 2013

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