Congestive Heart Failure (CHF) Treatment

Treatment for Congestive Heart Failure

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)

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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.

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