Brief summary
The purpose of this review article is to give a straightforward basic understanding of the basic concepts of the medical management of heart failure. As heart failure becomes more common and the cost becomes a larger burden on the economy all physicians should have a clear grasp of what is guideline driven therapy and some of the caveats of therapy. Physicians should also know when to refer patient for specialist’s management.
It is estimated that from 2010 to 2030 the prevalence of heart failure (HF) will increase by 25% yet the cost to the United States (US) economy during this same period will increase 215% (1). The impact on the population and the magnitude of cost demands that all physicians be versed in the optimal management of patients with heart failure. By optimal medical therapy we refer to that management which is guideline driven and cost effective. In this article we will discuss all the medications and therapies that have been proven to reduce mortality and hospitalizations in HF due to systolic dysfunction as it is commonly termed or HF with reduced ejection fraction (2) (3) (4). Although up to 40% of patient admitted to hospitals with diagnosis of HF have normal or nearly normal ejection fractions discussion of diastolic dysfunction or HF with preserved ejection fraction (HFPEF) is beyond the scope of this article. The definition of HF we will use for our patient in this article will be patients who have the clinical syndrome of HF whose hearts have an ejection fraction of 40% or less and are unable to keep up with the body’s metabolic requirements.
Beta Blockers
Beta blockers are the pinnacle of the triumvirate of heart failure medications composed of ACE inhibitors or angiotensin receptor blockers (ARB) if intolerant to ACEI, and an aldosterone blocker.
Only beta blockers with proven studies in HF should be used so the FDA approved alternatives in the US and PR are carvedilol (Coreg) (5) (6)and long acting metoprolol succinate (Toprol XL) (7) (3). The dosage of these medication should be optimized to maximum possible dose as tolerated by blood pressure and heart rate as of all medications used in HF these are the ones that increase LVEF the most and provide the largest reduction in mortality. (8).
Almost all ACE inhibitors are indicated for treatment of HF the difference is the frequency of dosing of each of these medications (3) (2). Captopril one of the most commonly used agents in Puerto Rico (PR) needs to be used three times a day, ramipril and enalapril have to be used twice a day yet agents such as lisinopril and monopril can be used once a day. The reason for using one agent over the other depends on the patient yet with the multiple medications needed for the treatment of HF and the patients comorbidities simplicity of therapy of once daily use can help increase compliance. The dose of medications should be optimized to the highest tolerated dose by the patients’ blood pressure.
A common mistake is withholding medication in patients with renal dysfunction in these patients medication should be used in low doses and only withheld if there is an increase in creatinine of 30% above baseline or if the patient has hyperkalemia (9).
Aldosterone blockers
Spironolactone (10) and eplerenone (11) have both demonstrated reduction in mortality of patients already on good medical therapy with ACE and beta blockers. They should be avoided in patients with creatinine clearance of 30mg/dL or less and or potassium levels of more than 5. Eplerenone has less side effects such as gynecomastia and can be used in patient with lower NYHA classes. Blood pressure should not be considered a limitation as study data demonstrated a mild increase in blood pressure in patient using eplerenone.
ARB’s
If patients are intolerant to ACE inhibitors an ARB can be an adequate substitute but only two medications in this class have FDA approval and studies to substantiate equivalence candasartan (Atacand) (12) which is used once daily and valsartan (Diovan) (13) which has to be used twice a day.
Digoxin
When used properly digoxin can reduce hospitalizations. It should be avoided in patients with severe renal dysfunction of eGFR of 30mg/dL, levels should be monitored at kept at 1or less. Use with amiodarone which increases digoxin serum levels should be avoided. (14) (15)
A common caveat in the use of all HF medications is blood pressure which due to the degree of dysfunction these patient tend to have low blood pressures so hypotension should only limit optimization of therapy by the patient expressing symptoms of hypotension and not the numeric value of the blood pressure reading.
Device therapy
Use of automatic implantable cardiac defibrillators (AICD) in combination, if appropriate, with cardiac resynchronization (CRT) can reduce mortality in patients with ejection fractions of 35% or less. All patients with these low ejection fractions need evaluation by a cardiologist to determine if they have criteria for use of these devices as these have recently changed (4).
Conclusions
All physicians should have a basic working knowledge of HF and the medications that need to be used. Beta blockers, ACE inhibitors and aldosterone antagonists are cornerstone therapies. These medications need to be used in appropriate doses and frequency and only the ones proven by studies and recommended by guidelines should be used. Cardiology evaluation, and when appropriate evaluation by heart failure specialist should be considered for optimization and addition of apropiate therapies such as electrical therapy with CRT and prevention of death with AICD.
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