Heart Failure: Treatment

Treatment of heart failure should target the underlying disorder: hypertension, coronary artery disease, diabetes, etc. See relevant chapters for specific information.

Oral Drugs

Diuretics are the first–line therapy for most heart failure patients, but are less useful (and may be contraindicated) for diastolic heart failure. Loop diuretics (eg, furosemide), thiazides (eg, hydrochlorothiazide), and potassium–sparing diuretics (eg, spironolactone) prevent volume overload and have favorable vascular effects.

Nitrates reduce cardiac preload through venous dilation.

Beta–blockers are a first–line treatment for all categories of heart failure, and are not limited to patients with coronary artery disease or hypertension. Carvedilol, metoprolol succinate, and bisoprolol have all been shown to decrease heart failure mortality.²

Angiotensin–converting enzyme inhibitors (ACEI) (eg, enalapril, lisinopril, ramipril) are also first–line heart failure treatments. They decrease mortality in a broad range of heart failure patients by decreasing afterload. 

Angiotensin II receptor blockers (ARB) (eg, losartan, candesartan, irbesartan) are generally equivalent to ACE inhibitors as first–line heart failure treatments, and they are often used if side effects (usually cough) limit ACEI use. Some patients benefit from combined use of ACEI and ARB, which more completely blocks the effects of angiotensin II.

Aldosterone blockers (eg, spironolactone, eplerenone) have been shown to decrease heart failure mortality when added to usual therapy,^3,4 but may be associated with risk for hyperkalemia.

Calcium channel blockers (eg, verapamil, diltiazem) may be used to treat myocardial ischemia and hypertension, but are not usual therapies for heart failure patients and are contraindicated for patients with significant systolic dysfunction.

Anticoagulants (eg, warfarin) can be used to prevent thromboembolism in heart failure, especially if systolic dysfunction is severe and/or sinus rhythm is absent. Benefit has not been clearly established for patients with less severe heart failure and sinus rhythm.

Digoxin is an oral inotropic agent that provides symptomatic relief in patients with decompensated heart failure, but it has not been shown to decrease mortality. It may be useful for patients who remain symptomatic despite optimal treatment with diuretics, ACEI or ARB, beta–blockers, and aldosterone blockers, especially if atrial fibrillation is present. Digoxin is not useful for diastolic dysfunction. Dosage must be adjusted for older patients or those with renal dysfunction, and in the presence of many drugs that influence digoxin serum levels. The therapeutic window for digoxin is narrow, and its use has become increasingly controversial as newer therapies have emerged.

Intravenous Medications

The following drugs are used for treatment of decompensation:

Nesiritide is administered intravenously for decompensated heart failure, often in an emergency or intensive care setting. Nesiritide has not been shown to improve 1–month or 6–month survival and is very expensive.

Dobutamine is an inotropic and vasoactive agent administered intravenously for symptom relief and systolic function improvement. It requires close monitoring, as it may produce dysrhythmias or abrupt blood pressure changes. It is sometimes used for home infusions after demonstrated acute efficacy, to relieve symptoms and decrease the need for hospitalization.

Phosphodiesterase inhibitors (eg, milrinone) increase contractility by modulating calcium influx into cardiac cells. They also facilitate both arterial and venous dilation, reducing preload and afterload. They are not used for chronic therapy, as this has resulted in increased mortality for heart failure patients.
In general, intravenous therapies for heart failure decompensation are intended to relieve symptoms and facilitate hospital discharge. They are not generally used for prolonging survival beyond the short term.

It is important to note that metformin and thiazolidinediones (eg, rosiglitazone) are contraindicated in patients with diabetes and concomitant heart failure. Thiazolidinediones may exacerbate heart failure by causing pulmonary and peripheral edema. Metformin increases the risk of lactic acidosis.

Surgical Procedures

Implantable cardioverter defibrillator (ICD) use has been shown to decrease mortality from lethal dysrhythmias for high–risk patients, particularly those with documented dysrhythmias and/or severe systolic dysfunction.

Intra–aortic balloon pump (IABP) is used to treat acute heart failure decompensation. IABP assists the heart by decreasing afterload and improving cardiac output. After insertion into the aorta via catheter, the balloon inflates at the beginning of diastole to enhance coronary perfusion. It deflates at the beginning of systole, thereby increasing cardiac output.

Cardiac transplant may be necessary for patients with end–stage heart failure. Left ventricular assist devices (LVAD) are used in extraordinary cases to bridge a severely ill patient to cardiac transplantation.

Other Treatments

Exercise conditioning, which should be approved by a physician and overseen by an exercise physiologist.

Leg elevation above the heart should be done during rest.

Compression stockings may help control leg edema and improve fluid removal. Results are variable, and a therapeutic trial will help determine usefulness for individual heart failure patients.

Prevention and treatment of heart failure also require lifestyle modifications, as described in Nutritional Considerations and Orders below.