Congestive Heart Failure (Part 3. Management)

Following 4 phases of heart failure must be in your mind when managing heart failure patients.

• Congestive heart failure with reduced ejection fraction (HFrEF).
• Heart failure with preserved ejection fraction (HFpEF).
• Acute decompensated heart failure (ADHF).
• Advanced heart failure.

General principles of treatment for heart failure

1. Relieve symptoms.
2. Improve functional status.
3. Prevent (re)hospitalization.
4. Prevent death.

General algorithm is following (each patient needs to be considered separately)

(See the typed out drug classes below the algorithm.)

• ACE Inhibitors or ARBs (consider H-ISDN if the patient cannot tolerate either of these drug classes.)
• MR Antagonists (anti-mineralocorticoids.)
• Ivabradine
• CRT-P/CRT-D
• Digoxin and/or H-ISDN (Hydralazine/Isosorbide Dinitrate)
• LVAD (Left ventricular assist device.)

Notes: 
Diuretics should be used to reduce the symtpoms of the congestion. They have, however, not shown to reduce rehospitalization of death.
ACEI/ARBs: titrate to evidence base dose or maximum tolerated dose below the evidence base dose.
Asymptomatic patient with LVEF =< 35% should be considred for ICD.
If MC receptor antagonist is not tolerated then an ARB can be added to ACEI.
European Medicine Agency has approved the use of Ivabradine in patients with heart rate >= 75 bpm.
CRT-P/CRT-D indication can vary depending upon the NYHA class, heart rhythm, QRS duration and morphology and LVEF.

Reference: Current Medical Diagnosis and Treatment 2016

Managing Heart Failure with Preserved Ejection Fraction (HFpEF)

Targets of the therapy are to reduce congestion, controlling the blood pressure, stabilizing the heart rate and improving exercise tolerance.

Clinical Pearls

Secondarily, managing sleep disorder and evaluation and correction of the ischemic heart disease are very important.

Excessive reduction in preload can cause underfilling of the heart leading to syncope.

Managing Heart Failure with Reduced Ejection Fraction (HFrEF)

Neurohormonal Antagonists

ACEI have shown to reduce mortality by 23% and 35% reduction in combined mortality and rehospitalization.

ACEI and ARBs have shown to safer when treating patients with renal insufficiency and tolerability in patients on beta blockers due to diabetes, asthma, and COPD.

Anti-mineralocorticoids

Aldosterone antagonists are shown to reduce mortality in all stages of the HF.

Eplerenone and spironolactone are observed to reduce mortality, rehospitalization and a significant reduction in sudden cardiac death.

Hyperkalemia and renal function deterioration must be kept in mind for patient with chronic kidney disease. Monitor renal function and potassium levels.

H-ISD (Hydralazine and Isosorbide Dinitrates) are shown to improve survival. This combination is not as significant as ACEI/ARBs, however, H-ISD can be used when a patient cannot tolerate ACEI or ARBs.

Heart Rate Modification

Ivabradine (Ivf channel inhibitor) slows heart rate without reducing the strength of pumping (no negative inotropic effect.)

Digoxin

Digitalis Glycosides are mild inotropes, sympathoinhibitor, and blunt the carotid sinus baroreceptor activity.

Studies show that digoxin can reduce the hospitalization in heart failure patients but does not reduce mortality or improve the quality of life. This drug should be used when nuerohormonal therapies are not working.

In low doses, digoxin can help achieve treatment goals. However, higher doses can be counterproductive.

Oral Diuretics

Loop diuretics may be required to counter the neurohormonal activation in heart failure patients. Dose adjustment is important. Usual need to use diuretics is to achieve volume control and then use neurohormonal therapy.

Additional Considerations

Inflammation control is needed.

Statins to reduce cardiovascular events and to improve survival.

Anticoagulants and Antiplatelet are administered as the HFrEF is associated with hypercoagulability states. Warfarin and Aspirin both have their own pros and cons. Current guidelines support the use of Aspirin in patients with ischemic cardiomyopathy.

Fish Oil can have modest improvement of the clinical outcomes.

Micronutrients are shown to be associated with heart failure. Reversible heart failure is observed with the deficiency of thiamine and selenium.

Enhanced External Counterpulsation (EECP) it is proposed that peripheral lower extremity therapy using graded pneumatic external compression maybe beneficial.

Exercise has shown to be safe, improves patients’ sense of well being and reduced mortality.

Sleep disorder breathing should be corrected.

Anemia is common in the HF patients.

Manage depression

Atrial Arrhythmias should be managed therapeutically or with external devices.

Managing Acute Decompensated Heart Failure (ADHF)

Congestion

In the hospital

Intravenous diuretics to rapidly manage the symptoms of congestion.

Start with loop diuretics. Thiazide diuretics (metolazone) combined with the loop diuretics when patient is on long-term diuretic therapy.

Weight change is a subjective metric.

Continue diuresis until euvolemia is achieved.

Cardiorenal Syndrome

This generally means the deterioration of heart when kidneys are managed or the deterioration of the kidney when heart is managed.

Possible inotropic therapy assisted circulation or cardiac transplant may be needed in the end stage disease.

Ultrafiltration

Invasive fluid removal with diuretics. Proposed benefit of this is to remove neutral fluids (less ionic imbalances compared to renal excretion.)

Vascular Therapy

Vasodilators (nitroprusside) can be used to attempt to stabilize ADHF.

Inotropic Therapy

Therapeutic agents that increase the intracellular concentration of cyclic adenosine monophosphate (cAMP) are beneficial. Sympathetic amines (dobutamine) and phophodiesterawse-3 inhibitors (milrinone) can be positive inotropes used.