Patient information: Heart failure treatments

HEART FAILURE OVERVIEW

Heart failure causes weakening of the heart, which limits the ability of the heart to pump. The name "heart failure" can be misleading, because the heart does not completely fail or stop, but instead it functions less effectively. Heart failure may range in severity from a moderate decrease in function without any symptoms to significant damage that leaves a person seriously weakened and very symptomatic.

The treatment of heart failure focuses on correcting or slowing the development of any conditions that led to the heart failure and managing the heart failure itself. Although heart failure is a serious condition, much can be done to manage the symptoms it causes and its impact on a patient's life.

This topic review discusses the options available for treatment of heart failure. A separate topic review discusses the causes, symptoms and diagnosis of heart failure. (See "Patient information: Heart failure causes, symptoms, and diagnosis".)

TREATING UNDERLYING CONDITIONS

A number of conditions can lead to heart failure, including high blood pressure (hypertension), coronary heart disease, a diseased heart valve, and cardiomyopathy. Slowing or reversing these conditions, when possible, is an essential part of the treatment of heart failure.

High blood pressure (hypertension) — High blood pressure creates a resistance that the heart must pump against. Long standing hypertension may result in development of heart failure. This frequently occurs due to hypertrophy (thickening of heart muscle). This increases the stiffness of the heart and causes "diastolic dysfunction."

Medications, such as angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), or beta blockers may be prescribed to treat both the elevated blood pressure and the heart failure itself. In addition, a diuretic is commonly prescribed to minimize excess body fluid that can contribute to increased blood pressure and cardiac workload. (See 'Heart failure medications' below.)

Coronary heart disease — Coronary artery disease affects the flow of blood and oxygen to the heart muscle. Without enough oxygen, the heart cannot work correctly. If the heart is severely deprived of oxygen for a long time, a heart attack (myocardial infarction) can occur, which kills heart muscle tissue.

Revascularization with catheter techniques or coronary artery bypass graft surgery (CABG [pronounced "cabbage"]) may be helpful in such patients. The catheter techniques can unclog blocked arteries by placing a stent in the diseased artery, while CABG uses a blood vessel taken from elsewhere in the body to bypass the obstruction.

Among patients with heart failure who have coronary artery disease, there are two main reasons to have revascularization:

• Episodes of chest pain, which mean that too little blood is flowing to the heart through the diseased vessel(s)
• Evidence from imaging studies that some of the heart muscle, fed by the diseased vessel, is still functioning.

Disease of the heart valves — The valves in the heart direct the flow of blood through the right side of the heart, through the lungs and back to the left side of the heart, and out to the rest of the body. Severe valve disease can lead to heart failure.

• When one of the valves becomes narrowed or stenotic, pressures behind the valve may increase significantly, making it harder for the heart to move blood forward and out of the heart.
• If the valve is damaged and cannot close completely, the valve becomes leaky, or "insufficient," and blood is pushed backwards (regurgitation). (See "Patient information: Mitral regurgitation".)

Surgery to replace or repair a diseased valve can improve the heart's function and may resolve the symptoms of heart failure, if the surgery is performed before the heart is permanently injured.

Cardiomyopathy — Cardiomyopathy, which is a disease of the heart muscle itself, is a condition marked by an enlarged, poorly functioning heart. A number of factors can cause it to develop, including hypertension; diabetes; coronary heart disease with or without a heart attack; exposure to a virus or toxin, such as alcohol; certain drugs; or other systemic diseases. A cardiomyopathy can also be inherited as a result of an abnormal gene. (See "Patient information: Dilated cardiomyopathy".)

The heart dysfunction of cardiomyopathy can sometimes be reversed by eliminating the cause (such as alcohol). When it cannot be reversed, the subsequent heart failure can be treated.

DIET AND LIFESTYLE CHANGES IN HEART FAILURE

Changes in diet and lifestyle are often recommended and may include one or more of the following:

• Decrease salt and water intake — Dietary salt (sodium) can contribute to excess fluid accumulation and may be restricted to two grams (2000 mg) of sodium per day. A detailed discussion about a low sodium diet is available separately. (See "Patient information: Low sodium diet".) Water intake also may be restricted in some cases.
• Reduce weight — Overweight people with heart failure may be advised to lose weight to reduce the heart's workload. (See "Patient information: Weight loss treatments".)

• Stop smoking — Cigarette smoking substantially increases the risk of heart attack and heart failure. Patients who smoke will be advised to stop. (See "Patient information: Smoking cessation".)

• Limit alcohol intake — Drinking excessive amounts of alcohol is not good for the heart. Anyone with heart failure should avoid drinking more than a moderate amount of alcohol (no more than one serving of alcohol per day for women and two for men). If the heart failure is due to alcohol-related cardiomyopathy, alcohol should be avoided completely.
• Cardiac rehabilitation and exercise — Patients whose heart failure is stable may be referred to a supervised cardiac rehabilitation program. Heart failure patients often find that exercise training helps to reduce shortness of breath and fatigue that can develop with normal daily activities. Becoming more active can improve quality of life and a sense of well-being. (See "Patient information: Heart attack recovery", in the section on cardiac rehabilitation).

HEART FAILURE MEDICATIONS

One or more medications may be prescribed to improve or slow deterioration of heart function, correct an abnormal heart rhythm, and prevent the formation of blood clots. This combined medical therapy significantly reduces the risk of death in people with heart failure.

Improving heart function — A number of drugs are used in combination to improve or slow the worsening of heart function and relieve symptoms. These drugs include:

ACE inhibitors and/or ARBs — A patient with heart failure is often started on an angiotensin converting enzyme (ACE) inhibitor and/or an angiotensin receptor (ARB). These agents are vasodilators, which means that they widen (dilate) the arteries and veins, making it easier for the heart to handle the body's blood volume and pump blood out of the heart.

If there are side effects with an ACE inhibitor (such as cough) an ARB may be substituted. Some people benefit from the combination of an ACE inhibitor and an ARB.

Beta blockers — Beta blockers slow the heart rate and reduce both the contraction of the heart muscle and blood pressure, thus decreasing the force with which the heart needs to contract. Beta blockers improve heart function, reduce symptoms of heart failure, and improve survival of heart failure patients.

Beta blockers are given in addition to an ACE inhibitor and/or ARB as well as other heart failure medications. Treatment starts with a very low dose that is gradually increased.

Aldosterone blockers — Aldosterone is a hormone that is produced in excess by the adrenal gland. It may contribute to the progression of heart failure and to abnormal heart rhythms. Aldosterone blockers (such as spironolactone or eplerenone) can increase survival in patients with heart failure who are also treated with ACE inhibitors/ARBs and beta blockers.

Digoxin — Digoxin was the first drug that was widely used to treat heart failure. It increases the heart's pumping force (called contractility), resulting in increased cardiac output. However, the effect of digoxin on survival appears to be closely related to the drug concentration in the blood.

It is essential to monitor blood digoxin blood levels and adjust the dose as needed. Higher blood concentrations can increase the risk of death while keeping blood levels within a narrow range may improve survival.

Diuretics — As heart function decreases in heart failure, the body tries to compensate by retaining salt and water. However, the poorly functioning heart has difficulty managing the additional fluid and it accumulates in tissues throughout the body. As it accumulates, it causes swelling (or edema) of the soft tissues, most noticeably in the legs, and congestion in the lungs. (See "Patient information: Edema (swelling)".)

Diuretics help the body get rid of the excess salt and fluid and improve the symptoms of leg edema and lung congestion. Diuretics are given only for symptom control.

Nitrates plus hydralazine — Nitrates and hydralazine dilate the blood vessels, making it easier for the heart to pump out blood. The combination of isosorbide dinitrate-hydralazine improves survival in black patients already treated with an ACE inhibitor and the other drugs described above.

This combination may be recommended for non-black people, especially if the standard heart failure medications have not reduced the person's blood pressure.

Correcting abnormal heart rhythms (arrhythmias) — Many people with heart failure develop an abnormal heart rhythm. In the normal heart, the heart chambers contract and relax in a coordinated, rhythmic manner. When the normal rhythm is disrupted, the heart rate often increases and the heart may no longer contract in a uniform fashion. Cardiac output often drops and the symptoms of heart failure can worsen. Some arrhythmias may not be associated with a worsening of symptoms, but may be potentially life-threatening, increasing the risk of cardiac arrest or sudden death.

A variety of arrhythmias can occur. Each must be evaluated separately and a treatment plan specific to that arrhythmia must be prescribed. Medications and a special pacemaker, known as an implantable cardioverter-defibrillator, are often used to restore the heart to a normal rhythm, prevent an arrhythmia, or minimize the frequency and effect of abnormal heart rhythms. In addition, special procedures may be performed to restore a normal rhythm or to evaluate the underlying cause of the rhythm disturbance. (See "Patient information: Pacemakers" and "Patient information: Implantable cardioverter-defibrillators".)

Blood clots and blood thinners — In heart failure, several factors increase the chance that blood clots may form in the heart and in the veins of the body. Blood flow through the heart is reduced by enlargement of the heart's ventricles, abnormal heart rhythms, and low cardiac output. As flow decreases, there is "sludging" or slowing of blood flow and an increased chance that a clot will form.

Once a clot forms, it can travel in the bloodstream and lodge in small vessels that feed other body structures. A blockage in the brain can cause a stroke, while a large blockage in the lung can be fatal. (See "Patient information: Pulmonary embolism".)

To avoid the problems caused by blood clots, a medicine to help prevent their formation (called an anticoagulant or a "blood-thinner") may be prescribed. This class of drugs, with warfarin being most widely used, requires careful monitoring. (See "Patient information: Warfarin (Coumadin®)".)

HEART FAILURE DEVICE THERAPY

Approximately one-third of deaths in people with heart failure are due to sudden death caused by certain abnormal heart rhythms (called arrhythmias). A device that shocks the heart to stop abnormal rhythms when they occur can improve survival in selected patients with moderate to severe heart failure.

These devices are called implantable cardioverter-defibrillators (ICDs). They are implanted under the skin or muscle in the chest. (See "Patient information: Implantable cardioverter-defibrillators".)

In addition to arrhythmias, people with heart failure can have abnormal conduction of electrical impulses. A special type of pacemaker can treat this problem and improve outcomes; this is called cardiac resynchronization therapy (CRT) or biventricular pacing. Most patients who are candidates for CRT are also candidates for an ICD and can be treated with a combined device. (See "Patient information: Pacemakers".)

HEART FAILURE SURGERY

Surgery may be recommended in people with heart failure who also have coronary heart disease or severe disease of the heart valves.

Heart transplant — People with severe heart failure may benefit from a heart transplant, which can improve survival and quality of life. However, because the supply of hearts for transplant is limited, eligible patients may have a lengthy waiting period. A mechanical left ventricular assist device (LVAD) may be used while the patient is awaiting transplantation. (See "Patient information: Heart transplantation".)

Left ventricular assist devices — Left ventricular assist devices are designed to assist the heart and improve the contractility of the left ventricle. They cannot replace the heart, but rather provide temporary support, acting as a bridge to transplantation (table 1).

However, there is a growing use of mechanical devices that assist or replace the heart in people who do not undergo transplantation (figure 1A-D). (See "Intermediate- and long-term mechanical cardiac support".)

LONG TERM OUTLOOK

Although heart failure is a serious condition, much can be done to manage its effects and its impact on a patient's life. The treatment of heart failure focuses on correcting or slowing the development of any conditions that led to the heart failure, and managing the heart failure itself. Treating an underlying condition, such as coronary heart disease, hypertension, or a diseased heart valve, is essential in slowing the progression of heart failure and relieving the associated symptoms.

Efforts to manage the heart failure itself focus on minimizing symptoms and optimizing the length and quality of the patient's life. Doctors recommend diet and lifestyle changes, including restricting salt intake, losing weight, and participating in a cardiac rehabilitation program to help patients manage the symptoms of heart failure and to improve their quality of life. Cardiac function in heart failure may also be improved with medications.

Treatments may be needed to prevent the life-threatening complications of heart failure, including abnormal heart rhythms and the formation of blood clots within the heart. (See 'Heart failure medications' above and 'Heart failure device therapy' above.)

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Heart failure causes, symptoms, and diagnosis
Patient information: Mitral regurgitation
Patient information: Dilated cardiomyopathy
Patient information: Low sodium diet
Patient information: Weight loss treatments
Patient information: Smoking cessation
Patient information: Heart attack recovery
Patient information: Edema (swelling)
Patient information: Pacemakers
Patient information: Implantable cardioverter-defibrillators
Patient information: Pulmonary embolism
Patient information: Warfarin (Coumadin®)
Patient information: Heart transplantation

Professional Level Information:
ACE inhibitors in heart failure due to systolic dysfunction: Therapeutic use
Angiotensin II receptor blockers in heart failure due to systolic dysfunction: Therapeutic use
Circulatory assist devices: Cardiopulmonary assist device and short-term left ventricular assist devices
Clinical manifestations and diagnosis of diastolic heart failure
Evaluation and management of asymptomatic left ventricular systolic dysfunction
Intermediate- and long-term mechanical cardiac support
Overview of the therapy of heart failure due to systolic dysfunction
Surgical management of heart failure
Treatment and prognosis of diastolic heart failure
Use of beta blockers in heart failure due to systolic dysfunction
Use of digoxin in heart failure due to systolic dysfunction
Use of diuretics in heart failure

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Heart, Lung, and Blood Institute

      (www.nhlbi.nih.gov)

• American Heart Association

      (www.americanheart.org)

• Heart Failure Online

     (www.heartfailure.org, also available in Spanish)

• European Society of Cardiology

      (www.heartfailurematters.org)

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