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 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).
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.
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.
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.
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).
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.
- Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Heidenreich PA, et Al. 2011, Circulation, Vol. 123, pp. 933–944.
- ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. McMurray, JJ et Al. 14, Jul 2012, Eur Heart J, Vol. 33, pp. 1787-1847.
- 2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Hunt, SA et Al. 53, Apr 2009, J Am Coll Cardiol, Vol. 14, pp. 1-90.
- 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force. Epstein Ae, et Al. 3, Jan 2013, J Am Coll Cardiol, Vol. 61, pp. 6-75.
- EFFECT OF CARVEDILOL ON SURVIVAL IN SEVERE CHRONIC HEART FAILURE. Milton P, et Al. 22, 2001, N Engl J Med, Vol. 344, pp. 1651-1658.
- Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): randomised controlled trial. Poole-Wilson PA, et Al. July 2003, Lancet, Vol. 362, pp. 7-13.
- Effects of controlled-release metoprolol on total mortality, hospitalizations, and well-being in patients with heart failure: the Metoprolol CR/XL Randomized Intervention Trial in congestive heart failure (MERIT-HF). MERIT-HF Study Group. Hjalmarson A, et AL. 10, Mar 2000, JAMA, Vol. 283, pp. 1295-1302.
- Impact of Initiating Carvedilol Before Angiotensin- Converting Enzyme Inhibitor Therapy on Cardiac Function in Newly Diagnosed Heart Failure. Sliwa K, et Al. 9, 2004, J Am Coll Cardiol, Vol. 44, pp. 1825-1830.
- Angiotensin-converting enzyme inhibitor-associated elevations in serum creatinine: is this a cause for concern? Bakris GL, Weir MR. 5, Mar 2000, Arch Intern Med, Vol. 160, pp. 685-693.
- THE EFFECT OF SPIRONOLACTONE ON MORBIDITY AND MORTALITY IN PATIENTS WITH SEVERE HEART FAILURE. Pitt B, et Al. 10, Sep 1999, N Engl J Med, Vol. 341, pp. 709-717.
- Eplerenone in Patients with Systolic Heart Failure and Mild Symptoms. Zannad F, et Al. 1, Jan 2011, N Engl J Med, Vol. 364, pp. 11-21.
- Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme. Pfeffer MA, et Al. Sep 2003, Lancet, Vol. 362, pp. 759-766.
- A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure. Cohn JN, et Al. 23, Dec 2001, N Engl J Med, Vol. 345, pp. 1667-1675.
- THE EFFECT OF DIGOXIN ON MORTALITY AND MORBIDITY IN PATIENTS WITH HEART FAILURE. Rekha G, et Al. 8, 1997, N Engl J Med, Vol. 336, pp. 525-533.
- Effect of Age on Mortality, Hospitalizations and Response to Digoxin in Patients With Heart Failure: The DIG Study. Rich MW, et Al. 3, Sep 2001, J Amc Coll Card, Vol. 38, pp. 442-445.