Overview of the therapy of heart failure with reduced ejection fraction
- Wilson S Colucci, MD
Wilson S Colucci, MD
- Section Editor — Heart Failure
- Professor of Medicine
- Boston University School of Medicine
Heart failure (HF) is a common clinical syndrome resulting from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. HF may be caused by disease of the myocardium, pericardium, endocardium, heart valves, vessels, or by metabolic disorders . HF due to left ventricular dysfunction is categorized according to left ventricular ejection fraction (LVEF) into HF with reduced ejection fraction (with LVEF ≤40 percent, known as HFrEF; also referred to as systolic HF) and HF with preserved ejection fraction (with LVEF>40 percent; known as HFpEF; also referred to as diastolic HF).
An overview of the management of chronic HFrEF will be presented here [1,2]. The management of acute HF, drugs that should be avoided or used with caution in patients with HF, the management of refractory HF, and therapy of HFpEF (diastolic HF) are discussed separately. (See "Drugs that should be avoided or used with caution in patients with heart failure" and "Management of refractory heart failure with reduced ejection fraction" and "Treatment and prognosis of heart failure with preserved ejection fraction" and "Treatment of acute decompensated heart failure: General considerations" and "Treatment of acute decompensated heart failure: Components of therapy".)
Goals of therapy — The goals of therapy of heart failure with reduced ejection fraction (HFrEF) are to reduce morbidity (ie, reducing symptoms, improving health-related quality of life and functional status, decreasing the rate of hospitalization), and to reduce mortality.
Major society guidelines — Several major societies and organizations have published guidelines for the treatment of HF [1-4]. These include the 2013 American College of Cardiology Foundation/American Heart Association guideline , the Canadian Cardiovascular Society guidelines , the 2012 European Society of Cardiology guidelines , the 2010 Heart Failure Society of America guidelines , and the 2010 National Institute for Health and Care Excellence chronic HF guideline .
With few exceptions, these societies make similar recommendations regarding the treatment of HFrEF. Our approach is in broad agreement with these guidelines.
- Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013; 128:1810.
- McMurray JJ, Adamopoulos S, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012; 33:1787.
- Heart Failure Society of America, Lindenfeld J, Albert NM, et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010; 16:e1.
- http://www.ccs.ca/index.php/en/resources/heart-failure-compendium (Accessed on August 24, 2015).
- https://www.nice.org.uk/guidance/cg108 (Accessed on August 25, 2015).
- Cohn JN, Ziesche S, Smith R, et al. Effect of the calcium antagonist felodipine as supplementary vasodilator therapy in patients with chronic heart failure treated with enalapril: V-HeFT III. Vasodilator-Heart Failure Trial (V-HeFT) Study Group. Circulation 1997; 96:856.
- Marwick TH. The viable myocardium: epidemiology, detection, and clinical implications. Lancet 1998; 351:815.
- Allman KC, Shaw LJ, Hachamovitch R, Udelson JE. Myocardial viability testing and impact of revascularization on prognosis in patients with coronary artery disease and left ventricular dysfunction: a meta-analysis. J Am Coll Cardiol 2002; 39:1151.
- Bortman G, Sellanes M, Odell DS, et al. Discrepancy between pre- and post-transplant diagnosis of end-stage dilated cardiomyopathy. Am J Cardiol 1994; 74:921.
- Jessup M, Brozena S. Heart failure. N Engl J Med 2003; 348:2007.
- Koelling TM, Aaronson KD, Cody RJ, et al. Prognostic significance of mitral regurgitation and tricuspid regurgitation in patients with left ventricular systolic dysfunction. Am Heart J 2002; 144:524.
- GENERAL CONCEPTS
- Goals of therapy
- Major society guidelines
- GENERAL MANAGEMENT
- Approach to management
- Manage contributing and associated conditions
- - Hypertension
- General management
- Renovascular disease
- - Ischemic heart disease
- - Valvular disease
- - Other associated conditions
- Lifestyle modification
- Pharmacologic therapy
- Device therapy
- Cardiac rehabilitation
- Heart failure disease management
- Serial assessment
- Preventive care
- MANAGEMENT OF REFRACTORY HF
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS