Congestive Heart Failure

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Treatment

Treatment for heart failure varies and involves reducing symptoms, treating the underlying cause of the condition when possible (e.g., antibiotics to treat pneumonia, restoring normal heart rhythm in patients with atrial fibrillation), and using medications to prevent further deterioration of heart function.

In mild cases, lifestyle modifications can help reduce symptoms such as fatigue, shortness of breath, and swelling (edema). These modifications may include dietary changes (e.g., restricted salt intake), abstaining from alcohol, and exercising regularly (only under the supervision of a physician).

Medications used to treat heart failure include the following:

• Angiotensin-converting enzyme (ACE) inhibitors (e.g., captopril [Capoten®], enalapril [Vasotec®], ramipril [Altace®], lisinopril [Prinivil®, Zestril®], quinapril [Accupril®], fosinopril [Monopril®], benazepril [Lotensin®], moexipril [Univasc®])
• Angiotensin II receptor blockers (ARBs; e.g., candesartan [Atacand®], irbesartin [Avapro®], losartin [Cozaar®], telmisartin [Micardis®], and valsartan [Diovan®]
• Beta-blockers (e.g., carvedilol [Coreg®], metoprolol [Lopressor®, Toprol XL®])
• Blood thinners (e.g., warfarin [Coumadin®])
• Diuretics (e.g., hydrochlorothiazide [HydroDIURIL®], chlorothiazide [Diuril®], furosemide [Lasix®], indapamide [Lozol®], bumetanide [Bumex®], spironolactone [Aldactone®], triamterene [Dyrenium®], metolazone [Zaroxolyn®], combination agents [Dyazide®])
• Inotropic agents (e.g., digoxin [Lanoxin®], dobutamine [Dobutrex®], dopamine)
• Other vasodilators (e.g., hydralazine [Apresoline®], isosorbide dinitrate [Isordil®], nitrates)

Angiotensin-converting enzyme (ACE) inhibitors help open (dilate) the arteries, making it easier for the heart to pump blood throughout the body. They usually are the treatment of choice for heart failure. Studies have shown that these drugs, which are often used to treat high blood pressure, can improve symptoms and reduce the risk for sudden death from heart failure.

ACE inhibitors usually are well tolerated and may be taken once a day, or 2 or 3 times daily. They are not used in patients with low blood pressure (hypotension) and may affect kidney function and potassium levels.

Side effects include the following:

• Chronic, nonproductive cough (occurs in about 10% of patients)
• Dizziness or weakness (caused by low blood pressure)
• Increased potassium levels
• Skin rashes
• Sudden swelling of the lips, face, and cheeks (if this occurs, the patient must seek medical attention immediately)

Angiotensin II receptor blockers (ARBs) may be used in patients who are unable to tolerate ACE inhibitors due to chronic cough, low blood pressure, or edema. These drugs, which help open (dilate) the arteries, are similar to ACE inhibitors, make it easier for the heart to pump blood, and may improve heart failure symptoms. Ongoing studies are investigating the use of ACE inhibitors with the use of ARBs in some patients with heart failure.

Angiotensin II receptor blockers generally are taken once a day, and they usually do not cause significant side effects. Rarely, they can impede kidney function.

Heart failure often causes the heart to pump harder to compensate for its weakened pumping ability. Beta-blockers help to relax the heart, reduce the vigor of its contractions, and reduce additional strain on the heart. These drugs often are used in combination with other drugs (e.g., ACE inhibitors, diuretics) to treat mild to moderate heart failure.

Beta-blockers are started at low doses that are gradually increased over a period of several months. During the first several weeks of treatment, some patients experience worsening symptoms due to a decrease in oxygen circulation in the body. Other side effects include low blood pressure, difficulty breathing, and nausea and weakness with exertion.

Heart failure increases the risk for stroke caused by blood clot (thrombus) formation and blood thinners (e.g., warfarin [Coumadin®]) often are prescribed to help reduce this risk. Blood thinners may cause nosebleeds and excessive bleeding and bruising.

In most cases, diuretics, commonly called "water pills," are prescribed to reduce fluid buildup in the body. These drugs cause the kidneys to excrete excess amounts of sodium and water into the urine, often reducing symptoms of heart failure (e.g., shortness of breath and swelling of the legs, ankles, and feet).

The correct diuretic dosage is based on the patient's weight. If not enough fluid is removed, heart failure symptoms do not improve and if too much fluid is removed, fatigue, low blood pressure, and impaired kidney function may occur. Diuretics usually are taken once (in the morning) or twice a day. In some cases, two diuretics are used to increase salt and fluid excretion.

Side effects include frequent urination and low potassium blood levels. Because of this, blood tests are performed periodically, and a potassium supplement is prescribed if blood levels are low.

Inotropic agents such as digoxin (Lanoxin®) and dopamine may be used in heart failure patients when ACE inhibitors and diuretics are ineffective. These drugs can help the heart pump more vigorously and can modestly increase the ejection fraction (percentage of blood pumped out of the left ventricle with each contraction), reducing heart failure symptoms.

Patients who are taking inotropic agents must undergo regular blood tests to monitor levels of the drug. They usually are well tolerated and side effects are rare when correct blood levels are maintained. Side effects include the following:

• Blurred vision
• Cardiac conditions (e.g., arrhythmias, heart block)
• Diarrhea
• Headaches
• Loss of appetite
• Low blood pressure (hypotension)
• Nausea and vomiting

Other vasodilators (e.g., hydralazine, isosorbide dinitrate, nitroglycerin) may be used in patients who are unable to tolerate ACE inhibitor therapy. Side effects include fainting or dizziness upon standing, headaches, and flushing.

Other Treatments
In some cases, heart failure persists or worsens in spite of treatment. An ultrafiltration process called aquapheresis, which uses a mechanical system called the Aquadex FlexFlow™, may be used to remove excess fluids and salt in CHF patients who do not respond to lifestyle modifications and medication.

In this treatment, blood is withdrawn using catheters (small tubes) inserted into veins in the arm, leg, or neck. The blood is then passed through a filter that removes excess fluid and is returned to the body. Studies have shown that ultrafiltration can remove more fluid at a faster rate than medication. The length of each treatment depends on the rate at which fluid can be removed from the body and the amount that must be removed.

Other treatments, which often depend on the cause of heart failure, include the following:

• Coronary angioplasty
• Coronary artery bypass surgery
• Implantable cardiac defibrillator (ICD)
• Intra-aortic balloon pump (IABP)
• Left ventricular assist device (LVAD)
• Valve repair or valve replacement surgery

Heart failure caused by reduced blood flow in the heart as a result of blockages (plaques) in one or more coronary arteries may be treated using coronary angioplasty. In this procedure, a hollow tube (catheter) is inserted through an artery (usually the femoral artery in the groin), into the coronary artery, and to the blockage. A small balloon is then inserted through the catheter and is inflated to open the blocked artery. There is a slight risk for damage to the artery during angioplasty, but heart failure symptoms usually improve following the procedure.

Coronary artery bypass surgery reroutes the blood supply around a blocked coronary artery. In this procedure, the surgeon removes a healthy section of an artery from another part of the body and attaches it to the coronary artery so blood can flow around the blocked section.

An implantable cardiac defibrillator (ICD) may be used to treat severe heart failure. An ICD is a small electronic device that is surgically implanted under the skin in the chest to monitor heart rhythm. When an abnormal rhythm is detected, the defibrillator delivers an electrical "shock" to the heart to restore normal heart rhythm.

An intra-aortic balloon pump (IABP) is a device that is inserted through an artery in the groin (femoral artery) and then placed within the main artery (aorta). An IABP is an inflatable balloon that expands and deflates in coordination with each heartbeat. It can be left in place for days to weeks, and decreases the strain on the heart, and increases blood flow throughout the body.

Patients with heart failure caused by an abnormal heart valve may require valve repair or valve replacement surgery. These are open-heart procedures in which an abnormal valve is repaired or replaced with a porcine valve (from pig tissue), a mechanical valve (made of synthetic material), or a homograft valve (from a human donor).

Complications include bleeding, blood clots, infection, kidney failure, stroke, heart attack, and death.

A left ventricular assist device (LVAD) is a mechanical pump that is surgically implanted in the upper abdomen to bypass the left ventricle and pump blood throughout the body. This device may be used in patients with end-stage heart failure who are awaiting heart transplantation. Long-term use of the device in patients with severe heart failure is being explored and defined.

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