Goals of Treatment for Congestive Heart Failure

Goals of treatment for patients with congestive heart failure (CHF) include improvement in the quality of life, reduction of acute episodes, and decreased mortality. An additional goal is to decrease the likelihood of arrhythmias, which may be a cause of sudden death in persons with heart failure. Other objectives in treating heart failure include controlling pulmonary congestion and edema, treating coronary artery disease, as well as controlling other co-existing conditions such as diabetes and high blood pressure.

Many new programs utilize nurses, nurse practitioners, or physician assistants to monitor patients at home by maintaining close telephone contact. Patients are usually asked to weigh themselves daily and to report an increase of three or more pounds. The goal is to maintain the "dry weight" determined by the health care provider, and to adjust medications accordingly if the patient is found to be retaining increased amounts of fluid.

Drug Therapy for Congestive Heart Failure

There are several types of drugs that have been proven to be effective for treatment of heart failure, not only for relieving symptoms, but for reducing the number of hospitalizations, increasing quality of life, and reducing mortality. Many of the medications used to treat CHF act by blocking some of the compensating mechanisms that are activated by cardiac dysfunction and reducing cardiac remodeling. While some medications may be used as monotherapy, many are used in combination in order to enhance the level of effectiveness. Additional information regarding drug therapy for heart failure and recommendations of the American College of Cardiology/American Heart Association (ACC/AHA) and the American College of Physicians (ACP) can be found in Annals of Internal Medicine (ITC6-1 - ITC6-116), 2010.

Drugs for heart failure include:

• Vasodilators - These drugs dilate or enlarge blood vessels so that the heart does not have to work as hard to pump the blood through the arteries. While there are several vasodilators available, two types have been proven to be very effective for the treatment of heart failure, namely ACE inhibitors and ARBs.
  • Angiotensin converting enzyme (ACE) inhibitors - ACE inhibitors [e.g., captopril (Capoten™), enalapril (Vasotec™), benzapril (Lotensin™)] are drugs that block the renin-angiotensin system. They lower blood pressure and make it easier for blood to leave the heart. ACE inhibitors are the most widely used vasodilators for the treatment of heart failure and should be used in all patients with left ventricular dysfunction regardless of NYHA class of symptoms, unless the patient has an intolerance to the medication or there is a contraindication such as angioedema (swelling in the tissue beneath the surface of the skin). ACE inhibitors reduce remodeling and have been proven to improve survival and quality of life in patients with heart failure. Side effects of ACE inhibitors include cough, worsening renal insufficiency, and hyperkalemia (elevated levels of potassium). These patients may be switched to ARB receptor blockers (see below) which do not cause this side-effect. ACE inhibitors must be used with care in persons who have significant kidney disease. There is some evidence that women do not benefit from ACE inhibitors as much as from other medications for heart failure.
  • Angiotensin II receptor blockers (ARBs) prevent the effect of angiotensin II at the level of body tissue and include candesartan (Atacand™), olmesartan (Benicar™), and valsartan (Diovan™). ARBs are typically considered for patients who cannot tolerate ACE inhibitors. Combining ACE inhibitors and ARBs may be beneficial in reducing left ventricular size and decreasing hospitalizations, but it is not clear if there is any effect on mortality. As with ACE inhibitors, ARBs must be used with care in persons who have significant kidney disease, and potassium levels must be monitored periodically while using these medications.
  • Calcium channel blockers - These medications are also vasodilators and are effective in improving diastolic function but they have not shown any benefit in prolonging life in CHF patients, although they may lower blood pressure. Some of the newer second-generation drugs such as amlodipine (e.g., Norvasc™), may have some benefit in patients with cardiomyopathy.
• Hydralazine (Apresoline™) is an arterial dilator and isosorbide dinitrate (Isordil™) is a nitrate that is a venous dilator. Each drug may be used as a monotherapy or they may be combined. When formulated as a combination drug called BiDil™, this medication decreases blood pressure and is an option when ACE inhibitors cannot be used because of the presence of kidney disease. BiDil is not quite as effective as ACE inhibitors but definitely offers benefits and helps to prolong survival. Studies have shown that hydralazine plus nitrates are especially effective in African American patients with CHF and may be added to the standard therapy of ACE inhibitors and ARBs.
• Beta-blockers [e.g., metoprolol (Toprol™), carvedilol (Coreg™), bisoprolol (Zebeta™)] - This class of drugs has demonstrated many benefits including slowing the heart rate (giving the ventricles more time to refill), lowering blood pressure, dilating the arteries, and reducing the workload of the heart, and reducing heart failure symptoms. Beta-blockers also have been shown to improve ejection fractions and significantly decrease mortality rates. Long-acting metoprolol and carvedilol have also been shown to decrease hospitalization and death due to CHF. Heart failure activates the sympathetic nervous system and causes more adrenaline-like substances to accumulate in the blood. This makes the heart work harder and beat faster, and can lead to dangerous arrhythmias. Beta-blockers prevent this by causing the heart not to work as hard or as fast. Heart rate must be monitored occasionally to be sure the heart rate is not being slowed too much (bradycardia). The AFP recommends that beta-blockers be used in patients with all NYHA classes of heart failure if they are stable on ACE inhibitors and do not have volume overload.
• Diuretics [e.g., furosemide (Lasix™), bumetanide (Bumex™), spironolactone (Aldactone™)] are used to stimulate the kidneys to pull excess fluid from the lungs, extremities, or abdomen and excrete the fluid as urine, thereby reducing the volume of circulating blood. Diuretics are used in patients who experience shortness of breath or have swollen legs and they are highly effective in reducing edema-related symptoms and improving exercise capacity. Diuretics are effective for people with both systolic and diastolic dysfunction. While diuretics provide relief of symptoms, they do not decrease mortality. Routine monitoring of the blood includes potassium and sodium levels as well as kidney function, which may be affected by these medications.
• Aldosterone antagonists [e.g. spironolactone (Aldactone™) and eplerenone (Inspra™)] may increase survival in patients with heart failure. The addition of low dose aldosterone antagonists is recommended for patients who continue to have NYHA class III to IV symptoms despite therapy with ACE inhibitors and beta-blockers. Potassium levels must be monitored weekly while patients are using ACE inhibitors and spironolactone. Their benefit on systolic heart failure has been borne out in clinical trials, while benefit for diastolic dysfunction remains unclear. Spironolactone is an older aldosterone antagonist and has been studied extensively in heart failure. It occasionally causes gynecomastia (breast enlargement) in men. Eplerenone is a newer aldosterone antagonist that is highly effective and has fewer side effects than spironolactone.
• Inotropic Agents - Drugs that strengthen the contraction of the heart so that it pumps more forcefully are known as inotropic agents and include digoxin (Lanoxin™). Digoxin alleviates symptoms and decreases hospitalization rates in patients with heart failure but not been shown to decrease mortality. Digoxin is used primarily as an add-on medication to other medications such as ACE inhibitors. The ACC/AHA recommends that digoxin be combined with a beta-blocker for heart rate control in heart failure patients with atrial fibrillation.
  • Newer inotropic agents called phosphodiesterase inhibitors, include milrinone (Primacor™) and dobutamine that is sometimes administered in severe cases by intravenous drip for 72 hours every three or four weeks to improve symptoms of congestive heart failure. These medications, however, are not useful in persons with diastolic dysfunction. They may be used to bridge a patient to insertion of a left ventricular assist device or heart transplantation. The ACP notes that all inotropic agents, except digoxin, have been association with excess mortality and are therefore considered only for patients who do not respond to other medications for heart failure
• Natriuretic peptides (BNP) - Nesiritide (Natrecor™) is a new medication which is a recombinant form of a peptide produced by the wall of the ventricle (BNP). It promotes vasodilation, excretion of sodium in the urine, and increased urine production, thereby relieving pulmonary congestion. Intravenous nesiritide is effective in rapidly stabilizing a patient whose heart failure has become suddenly worse. Nesiritide injection was approved in 2001 by the U.S. Food and Drug Administration (FDA) for treatment of decompensated heart failure (exacerbated heart failure requiring immediate intervention).
• Amiodarone - Newer agents include amiodarone (e.g., Cordarone™ or Pacerone™), an anti-arrhythmia medication that prevents sudden death and which, in certain studies, appeared to improve survival in patients with heart failure.
• Nitroglycerin (paste or patch) - Although nitroglycerin is used mainly for patients with chest pain (angina), it can also be used to treat heart failure because it dilates the veins of the body, forcing blood to pool away from the heart.
• Statins - The benefit of statins (cholesterol-lowering drugs) in patients with heart failure is a subject of continuing debate. There is evidence that statin treatment may slow disease progression in heart failure, particularly in patients with CAD. To read more about statins for treatment of heart failure, please click on the following link: http://www.ncbi.nlm.nih.gov/pubmed/20234351

Implantable Device Therapy for Congestive Heart Failure

Most people with congestive heart failure (CHF) can be managed effectively with medications; however, some patients with CHF may require treatment with certain implantable devices. Implantable devices that may be used in select patients with CHF include: