Treatment Advances for Patients With Heart Failureby Nicole Van Hoey, PharmD Health Professional
Congestive heart failure (CHF) — present in 6 million American adults — develops when the heart muscle cannot pump enough blood around the body. Despite improvements in care, the disease is difficult to control long term, and hospitalizations remain commonplace.
Symptoms and causes
The severity of heart failure is graded by New York Heart Association classes according to symptoms and a measure of the heart muscle’s ability to pump blood (ejection fraction). The most common symptoms of heart failure are increasing tiredness, shortness of breath, and swelling in the stomach or ankles.
You can develop heart failure because of existing heart disease, like coronary artery disease or hypertension, or from conditions that weaken the heart, like diabetes or excess alcohol use.
Expert treatment algorithms for heart failure
In addition to lifestyle changes, treatments to minimize symptoms of heart failure can increase quality of life and reduce the risk of death. As the heart weakens, fluid may collect in the lungs causing weight gain, trouble breathing while lying down, and coughing. Often, multiple medications, and sometimes devices or surgery, are needed to reduce the stress on the heart and lungs. Diuretic and antihypertensive medicines are commonly used to treat these sypmtoms.
Controlling symptoms: removing excess fluid
Excess fluid - or edema - adds even more stress to the heart, lungs, and kidneys. Diuretics, like furosemide, can eliminate symptoms, like shortness of breath and sluggishness, but aggressive use can cause an potassium imbalance. Dehydration, dry mouth, and muscle cramps are other side effects of high diuretic doses. Periodic lab measures of sodium and potassium, as well as weight checks at home to monitor fluid levels, help doctors adjust the drug doses safely.
Antihypertensives: a care standard
Typically used to treat high blood pressure, ACE inhibitor drugs also help patients with CHF by lowering hormones that stress the heart and by relaxing blood vessels to make blood flow easier. Similarly, angiotensin receptor blockers (ARBs) relax blood vessels, too, in patients who cannot tolerate ACE inhibitors. Use of antihypertensive drugs also decreases the risk of heart attack. However, both drug classes can lower potassium levels. ACE inhibitors can cause a dry cough and angioedema.
2017 Guideline update: neprilysin inhibitors
The American College of Cardiology, American Heart Association, and Heart Failure Society of America maintain treatment guidelines for all types of heart failure. In 2017, the guidelines were updated to include a new treatment class: neprilysin inhibitors. The first of this class to be approved is sacubitril, in a combined form with valsartan, an ARB (together called an ARNI medicine).
Neprilysin inhibitors cont.
Neprilysin inhibitors promote enzymes in the body that remove sodium and relax blood vessels; they appear to reduce CHF symptoms and cardiac death better than standard treatments (e.g., ACE inhibitors). ARNIs cannot be given at the same time as an ARB alone, and you must wait 36 hours between stopping an ACE inhibitor and starting an ARNI to avoid angioedema.
Arrhythmia development and concerns
When the heart begins to fail, ventricles and atria stop working together. The heart rate slows too much or skip beats, or parts of the muscle can quiver. Patients with CHF, even at mild stages, are at risk for ventricular arrhythmias like fibrillation, when the ventricles shake without pumping blood and oxygen does not reach other parts of the body. Patients with rhythm problems may need treatment to steady the heart rate, but many anti-arrhythmia medicines are unsafe in patients with CHF.
When devices are needed to control heart rhythms
When the heart muscle needs repeated, or even continual, reminders to beat in sequence, and medicines are not enough, different devices can help instead. Two types of devices, pacemakers and implantable cardioverter defibrillators (ICDs), give health professionals the ability to control a patient’s heart rate and pumping ability on demand - exactly when an arrhythmia occurs.
Pacemakers may be temporary or permanent, with an internal or external battery generator and leads (wires) under the skin. These leads send electrical messages to regularly contract the heart muscle. Conversely, defibrillators provide both low shocks to reset irregular heartbeats and bigger shocks to counter dangerous ventricular arrhythmias. Like pacemakers, ICDs use a battery and leads into the heart, but the device is placed under the skin in the chest or abdomen.
ICD benefits and drawbacks
For patients whose heart arrhythmias impair normal function and increase mortality, ICDs are amazing tools that offer peace of mind during everyday situations and exercise. Surgery to insert the device is considered minimally invasive, not open chest. However, ICDs are not without risks: they can deliver shocks incorrectly, and infection is possible at the implantation site. ICD use in some patients, in particular those without other heart disease, may have little mortality benefit.
Patient confusion and worry are prevalent, too: anxiety and depression about shock sensations can reach as high as 40 to 50 percent. Few patients realize that the device can be turned off, might need replaced, or can affect end-of-life discussions. Cardiologists are an underused source of knowledge about ICD concerns. If you need an ICD, bring a list of questions to appointments before and after implantation to stay informed.
Alternative defibrillator options: external wearables
In patients who are waiting for ICD surgery, or in patients who decline or cannot tolerate ICD implantation, external defibrillators are needed. A newer option to reset the heart fills this void in a wearable form. Approved by the FDA in 2001, external defibrillator vests fit underneath clothing. A battery pack is attached to the waist, and dry, nonadhesive electrode sensors in the snug vest measure the heart rhythm. Before giving a shock, the vest releases gel to conduct the shock correctly.
External wearables cont.
Potential benefits include continuous coverage when an ICD battery needs to be replaced. Wearable defibrillators have been approved by the Centers for Medicaid and Medicare Services, setting a standard for insurance reimbursement. However, the new technology still has unresolved concerns. For example, patients must monitor battery and gel release functions themselves, gel pads must be replaced after each shock, and compliance with wearing the vest for at least 22 hours each day is variable.
CHF care: chronic but complex
With advances in medications and devices to treat CHF, patients are living longer and with fewer symptoms. Still, CHF care is complex and requires constant attention to avoid slowly worsening symptoms or life-threatening arrhythmias. Devices in particular are challenging to understand and live with. If you have CHF, you can learn more about living with the disease, about defibrillator options, and about obtaining printable defibrillator wallet cards at the American Heart Association website.