An Overview of Heart Failure Treatments and Updates for the Primary Care Clinician
Heart failure is structural or functional cardiac impairment that leads to an inability of the ventricles to fill and eject blood. Treatment depends on the severity of cardiac dysfunction which is measured as the ejection fraction. Standard treatment guidelines for the primary care clinician are presented here along with the newest updates for treating heart failure with reduced ejection fraction.
Heart Failure with Preserved Ejection Fraction of >50% (previously known as diastolic heart failure)
Evidence shows that treatments used in patients with heart failure with reduced ejection fraction do not provide the same reduction in morbidity and mortality in patients with heart failure with preserved ejection fraction (1). Therefore, the treatment of a patient with heart failure with preserved ejection fraction revolves around managing comorbidities that lead to worsening heart failure. This means treating hypertension, coronary artery disease, atrial fibrillation, obesity, kidney disease, diabetes, and sleep apnea (2). Many of the specific treatments for patients with heart failure with preserved ejection fraction are based on the 2013 American College of Cardiology and American Heart Association guidelines for the management of heart failure (3).
- People who are treated for hypertension are less likely to have fatal coronary heart disease and myocardial infarction, problems that lead to heart failure.
- The choice of antihypertensive agents for patients with preserved ejection fraction is less clear because specific studies do not show improved mortality with one agent versus another in these patients. Analysis of the ALLHAT study shows that the use of chlorthalidone for hypertension reduces new-onset heart failure hospitalization rates. However, the use of all other agents including beta-blockers, calcium channel blockers, ACE inhibitors, and angiotensin receptor blockers does not show mortality benefit in people with heart failure with preserved ejection fraction (4,5).
- People who undergo exercise training have an improved quality of life, but exercise does not change left ventricular function or disease progression (6).
- Compared with nonobese subjects, obese people with heart failure with preserved ejection fraction develop more significant symptoms as the disease progresses, so it is thought that preventing obesity prevents rapidly worsening heart failure (7).
- Randomized trials have not been done to determine whether people with heart failure with preserved ejection fraction benefit from the use of statins, but an observational study shows that people treated with stains have improved overall outcomes (8).
Heart Failure with Reduced Ejection Fraction of <40% (previously known as systolic heart failure)
Similar to people with heart failure with preserved ejection fraction, people with reduced ejection fraction should be monitored and treated for comorbidities that contribute to overall heart disease and heart failure, including hypertension, coronary artery disease, atrial fibrillation, obesity, kidney disease, diabetes, and sleep apnea. Although randomized trials have not been done, observational studies and expert opinion suggest that patients should quit smoking tobacco (9), limit alcohol consumption (10), and avoid excessive salt intake (3). There is little evidence to recommend sodium restriction, but experts recommend avoiding excessive salt intake (>6 g/day) (11).
- General Pharmacologic Management Including Blood Pressure Control
- Appropriate treatment of people with heart failure with reduced ejection fraction leads to the greatest decrease in hospitalization rates and mortality. Standard therapy with a renin-angiotensin system blocker plus a beta-blocker improves mortality (3). People with edema or fluid overload also benefit from the addition of a diuretic.
- Treatment of hypertension is based on the 2016 American College of Cardiology updated decision pathway for people with heart failure with reduced ejection fraction. Patients show mortality benefit when treated with either an ACE inhibitor or an angiotensin receptor-blocker plus a beta blocker. However, new guidelines show improved outcomes by switching patients from these regimens to an angiotensin receptor-neprilysin blocker plus a beta-blocker. Evidence-based beta blockers include metoprolol, carvedilol, and bisoprolol. If a person cannot tolerate an angiotensin system blocker then experts recommend hydralazine plus nitrates instead (12).
- In addition to an angiotensin receptor-neprilysin blocker and a beta-blocker, patients who continue to have a resting heart rate above 70 have improved outcomes with the use of ivabradine. The goal resting heart rate is 50–60 bpm (13).
- Sodium-glucose cotransporter-2 drugs are used in patients with diabetes, but new evidence shows that even people without diabetes have improved clinical outcomes and decreased hospitalization rates (14).
- All of these recommendations are highlighted even further in the newest evidence published in The Lancet in July 2020. The study emphasizes comprehensive treatment with a mineralocorticoid receptor antagonist, an angiotensin receptor-neprilysin inhibitor, a beta-blocker, and a sodium-glucose cotransporter-2 inhibitor. This combined comprehensive treatment plan significantly reduces hospitalization rates and mortality compared to previously recommended treatments. For patients age 55, the combined therapy is estimated to add 8 more years of life before hospitalization for heart failure or death (15).
- Two large randomized controlled trials show that people have a reduction in cholesterol levels with the use of rosuvastatin, but statin use does not reduce mortality. At this time, experts do not recommend regular statin use in people with heart failure with reduced ejection fraction (16,17).
- Cardiac Resynchronization Therapy and Implantable Cardioverter-Defibrillator (CRT and ICD)
- People with heart failure with a reduced ejection fraction and a wide QRS complex have higher mortality than people with a narrow QRS complex (18). Therefore, experts recommend cardiac resynchronization therapy to pace the left and right ventricles simultaneously and improve cardiac function. People who are medically optimized and who have a reduced ejection should be referred for CRT evaluation, especially if the person has a wide QRS complex and ejection fraction <35% (19).
- Most people who meet the criteria for cardiac resynchronization also meet the criteria for an implantable cardioverter-defibrillator. There are no studies that show a significant benefit to adding a defibrillator over a pacemaker (20). Each patient should be evaluated individually to decide which device is best.
Heart Failure With Mid-Range Ejection Fraction of 41-49%
It is important to know that this category of heart failure exists, but specific studies evaluating treatment of heart failure with mid-range ejection fraction do not exist. Heart failure studies usually include patients with either a preserved ejection fraction or reduced ejection fraction. In general, people with heart failure with mid-range ejection fraction respond to therapy in similar ways as people with heart failure with reduced ejection fraction.
Refractory Heart Failure With Reduced Ejection Fraction
People with heart failure with reduced ejection fraction need to be followed regularly, preferably every 3–6 months, to monitor their clinical stability. Cardiac rehabilitation should also be utilized. Most people respond to optimal medical management, but some continue to decline. People with chronic heart failure complain of symptoms at rest or with minimal exertion. People with chronic heart failure symptoms who have been medically optimized are classified as refractory heart failure patients with reduced ejection fraction. At this point, they benefit from referral to a heart failure specialist (12). Advanced therapies including intravenous vasodilators, inotropic therapies, mechanical circulatory support, cardiac transplantation, and palliative care may be necessary.
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