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The treatment of heart failure includes determination and treatment of the cause, removal of any precipitating factors, appropriate patient education, general non-pharmaceutical measures and drug treatment. Studies have shown the benefit of an integrated, multidisciplinary approach to management.
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Prevention of heart failure
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The emphasis on prevention is very important since the onset of heart failure is generally associated with a poor prognosis. Approximately 50% of patients with heart failure die within 5 years of diagnosis.7
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The scope for prevention includes the following measures:8
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dietary advice (e.g. achievement of ideal weight, optimal nutrition)
emphasising the dangers of smoking and excessive alcohol
control of hypertension
control of other risk factors (e.g. hypercholesterolaemia)
early detection and control of diabetes mellitus
early intervention during myocardial infarction to preserve myocardial function (e.g. thrombolytic therapy)
secondary prevention after the occurrence of myocardial infarction (e.g. beta blockers, ACE inhibitors and aspirin)
appropriate timing of surgery or angioplasty for ischaemic or valvular heart disease
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Treatment of causes and precipitating factors
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Any underlying cause should be identified and treated, if possible. Precipitating factors that should be treated include:
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arrhythmias (e.g. atrial fibrillation)
electrolyte imbalance, especially hypokalaemia
anaemia
myocardial ischaemia, especially myocardial infarction
dietary factors (e.g. malnutrition, excessive salt or alcohol intake)
adverse drug reactions (e.g. fluid retention with NSAIDs and COX-2 agents) (see TABLE 88.2)9
infection (e.g. bronchopneumonia, endocarditis)
hyper- and hypothyroidism
lack of compliance with therapy
fluid overload
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Note: Be mindful of complementary medications.
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General non-pharmacological management
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Education and support
Smoking: encourage no smoking
Refer for a rehabilitation program with interdisciplinary care
Encourage physical activity especially when symptoms absent or mild
Rest while symptoms are severe
Weight reduction, if patient obese
Advice on food supplementation—dietitian
Salt restriction: advise no-added-salt diet (<2 g or 60–100 mmol/day)
Water restriction: water intake should be limited to 1.5–2 L/day or less in patients with advanced heart failure, especially when the serum sodium level falls below 130 mmol/L7
Limit caffeine to 1–2 cups coffee/tea a day
Limit alcohol to 1 standard drink a day
Fluid aspiration—if pleural or pericardial effusion present
Daily weighing—check significant weight gain or loss
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Other general measures1
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Optimise cardiovascular risk factors (e.g. BP, lipids, HbA1C)
Monitor emotional factors including depression
Regular review
Vaccination: annual influenza, 5-yearly pneumococcus
2-yearly echocardiography (or more) as indicated
Pleurocentesis or pericardiocentesis (if applicable)
Treat co-existing obstructive sleep apnoea
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Drug therapy of heart failure due to left ventricular systolic dysfunction
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Any identified underlying factor should be treated.
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Evidence from RCTs shows the beneficial results from ACE inhibitors2,9 (or angiotensin II blockers), digoxin (improves outcome in people already receiving diuretics and ACE inhibitors), beta blockers and spironolactone (in severe heart failure).
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Atrial fibrillation should be treated with digoxin. Vasodilators are widely used for heart failure and angiotensin converting enzyme inhibitors (ACEI) are currently the most favoured vasodilator.
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Note: Monitor and maintain normal potassium level in all patients.
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ACE inhibitors improve prognosis in all grades of heart failure and should be employed as the initial therapy in all patients, except where contraindicated (e.g. kidney artery stenosis, angioedema).
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Diuretics have an important place in patients with fluid overload. As a rule they should be added to an ACEI to achieve euvolaemia. Diuretics should be used in moderation and excessive doses of a single drug avoided. In patients with systolic LV dysfunction they should not be used as monotherapy.8 Close monitoring of weight, kidney function and electrolytes is required. Loop diuretics such as frusemide, bumetanide or ethacrynic acid are commonly used, especially for heart failure of moderate severity.8 Thiazide and related diuretics produce a gradual diuresis and are recommended for mild heart failure. Examples include hydrochlorothiazide, bendrofluazide, chlorthalidone or indapamide.
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Initial therapy of heart failure7,10
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ACE inhibitor (start low, aim high)
Dosage of ACE inhibitor: commence with ¼ to ½ lowest recommended therapeutic dose and then adjust it for the individual patient by gradually increasing it to the maintenance or maximum dose (see TABLE 88.3). Once-daily agents are preferred. Use an ARB if cough is problematic.
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ACE inhibitors are regarded as the agents of first choice because they correct neuroendocrine abnormalities and reduce cardiac load by their vasodilator action.
Every effort should be made to up-titrate to the highest tolerated dose.
Consider giving the first dose at bedtime if there is a risk of orthostatic hypotension.
If the ACEI is not tolerated (e.g. due to cough) consider an angiotensin II receptor blocker (ARB) as they have proven benefit in CHF.11
In practice the usual initial treatment of heart failure is an ACE inhibitor plus diuretic. This combination optimises response and improves diuretic safety.
Consider stopping any diuretic for 24 hours before starting treatment with an ACEI.
Potassium-sparing diuretics or supplements should not be given with ACEI (or should at least be used with caution) because of the danger of hyperkalaemia.
Kidney function and potassium levels should be monitored in all patients.
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Some authorities are concerned about the over-reliance on diuretics and also about compliance as well as side effects. Once the diuretic effect has been achieved, diuretics may be withdrawn and fluid restriction advised. The ACEI is then used alone or with a beta blocker.
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Selective beta blockers have been shown to prolong survival of patients with mild to moderate CHF taking ACE inhibitors who are stabilised. Start with extremely low doses (see TABLE 88.4). Commence when patient stable and euvolaemic.
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Digoxin was the mainstay of treatment of heart failure for decades prior to the use of ACE inhibitors. It was an effective agent but limited. The two indications for its current use are in patients with atrial fibrillation to control rapid ventricular rate and in patients with sinus rhythm not adequately controlled by the other agents above it in FIGURE 88.1. Most patients are started on a low dose digoxin:
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Ivabradine is a direct sinus node inhibitor which can be added to a beta blocker in patients with continuing symptoms of moderate to severe failure, or where beta blockers are contraindicated or not tolerated. Other new agents to consider for optimal treatment include sacubitril/valsartan (Entresto)—an angiotension/neprilysin inhibitor.
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Heart failure (unresponsive to first-line therapy)—stepwise strategy2,7
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ACE inhibitor
plus
frusemide 40–80 mg (o) bd
plus
spironolactone 12.5 (starting)—25 mg (o) daily (monitor potassium and RFTs), if still congestion
plus
a selective beta blocker (if patient euvolaemic)
plus
digoxin (if not already taking it):7 loading dose:
– 0.5–0.75 mg (o) statim (depending on kidney function)
– then 0.5 mg (o) 4 hours later
– then 0.5 mg the following day
– then individualise maintenance
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Severe heart failure7,10
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Hospital with bed rest.
ACE inhibitor to maximum tolerated dose
plus
frusemide to max. 500 mg/day
plus
spironolactone (low dose) 25 mg/day
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If poorly controlled, consider adding:
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If still uncontrolled consider vasodilators other than ACEIs or ARBs:
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A glyceryl nitrate patch can be used for the relief of symptoms, especially nocturnal dyspnoea.
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Consider cardiac transplantation for appropriate patients with end-stage heart failure (e.g. patients under 50 with no other major disease). Other surgical options include heart valvular surgery, coronary artery bypass surgery and surgical ventricular restoration (surgical reduction of an enlarged left ventricle).
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A flow chart for the basic management of heart failure is presented in FIGURE 88.1.
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Diastolic heart failure2,8
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Management is based on treating the cause such as hypertension, ischaemia and diabetes. The basic treatment is with inotropic agents such as calcium channel blockers (verapamil or diltiazem) and beta blockers. If possible avoid diuretics (except for congestion), digoxin, nitrates/vasodilators and nifedipine. Excessive diuresis from overzealous diuretic therapy can cause severe consequences for cardiac output. ACE inhibitors can be used with caution.
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Pitfalls in management
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The most common treatment error—excessive use of diuretics3
Giving an excessive loading dose of ACE inhibitor
Failure to correct remedial causes or precipitating factors
Failure to measure left ventricular function
Failure to monitor electrolytes and kidney function
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Acute severe heart failure
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For the treatment of acute pulmonary oedema refer to CHAPTER 128.
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ACE inhibitors, beta blockers and spironolactone have been shown to improve survival in CHF.9
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Device-based heart failure treatments1
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The use of mechanical devices to treat patients with severe failure is gaining momentum. Devices include:
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The evidence for the efficacy of these devices is good, but limitations include cost and infection. Biventricular pacing or cardiac resynchronisation therapy resynchronises cardiac contraction in patients with systolic CHF and left branch bundle block. VentrAssist is based on a continuous flow rotary blood pump that is surgically implanted in the abdominal wall and attached to the apex of the ventricle.