Outpatient Management of CHF

Pharmacologic Treatment

• ACE Inhibitors ---> Decrease the rate of mortality in all patients with systolic heart failure. Good tolerability, with dropout rates of 15 to 30 percent secondary to dizziness, altered taste, hypotension, hyperkalemia and cough.

• ARBs ---> similar efficacy to ACE inhibitors, however they do not cause cough.

• Beta Blockers ---> The following have all been proven to help reduce mortality in patients already taking an ACE inhibitor and/or diuretic.

• Bisoprolol (Zebeta)

• Metoprolol (Toprol XL)

• Carvedilol (Coreg)

• Spirinolactone (Aldactone) ---> Can benefit patients with moderate to severe heart failure.

• Hyperkalemia is the most common adverse event

• 10% of men taking this experience breast pain and gynecomastia

• Eplerenone (Inspra) is a more selective aldosterone inhibitor that has also shown some efficacy.

• Hydralazine + Isosorbide Dinitrate ---> Reduces mortality, but is less tolerable than other medications.

• Digoxin* ---> Effective in relieving symptoms of heart failure in the absence of dysrhythmias.

• Diuretics* ---> Mainstay of symptomatic treatment, improving symptoms of sodium and fluid retention, helping to increase exercise tolerance and cardiac function.

• Antiplatelet/Anticoagulation Therapy ---> Only recommended for patients with heart failure and atrial fibrillation/previous embolic event. Otherwise may adversely affect some medications or have no beneficial effects.

Overview

Heart failure affects almost 5 million adults and >10% of people over 65 years old and is responsible for nearly 4 million outpatient visits per year. The Framingham Heart Study shows that heart failure is very lethal, with a five year survival rate of 25% in men and 38% in women.

Treatment of Systolic Heart Failure

1. Control of risk factors for the development and progression of heart failure

2. Treatment of heart failure

3. Education of patients

Treatment of Diastolic Heart Failure

1. Diuretics to decrease fluid volume

2. Calcium channel blockers to promote left ventricular relaxation

3. ACE Inhibitors to promote regression of left ventricular hypertrophy

4. Beta blockers/Antiarrhythmic agents to control rate/maintain atrial contraction

Non-Beneficial/Harmful Treatments

1. Calcium Channel Blockers (Systolic Heart Failure)

   1. Norvasc may be safe, but there is no evidence of any benefit

   2. Older, shorter acting CCBs can worsen heart failure

2. Positive Inotropic Therapy

   1. Increased mortality, increased hospitalizations and serious side effects

Nonpharmacologic Management

• Dietary Sodium Restriction*

• Restrict to <2g>

• Exercise

• Moderate  60% of maximum exercise capacity on a stationary bike for 2-3 hours/week

• Improves quality of life, decreases mortality and hospital readmissions

Suggested Overall Management

Four categories that should be addressed simultaneously

1. Risks for developing and advancing heart failure need to be treated

   1. Hypertension, diabetes, thyroid disease, and myocardial infarction

   2. Use of alcohol and tobacco

2. Treatment of Heart failure

   1. Started on one or more medication

   2. Baseline medical management

      1. ACE inhibitor (or ARBs)

      2. Beta Blockers

   3. For severe heart failure

      1. Spironolactone and Carvedilol can be added

   4. Begin and maintain a regular aerobic exercise program

   5. Digoxin, if already started should be maintained, does improve symptoms

3. Control of Symptoms

   1. Diuretics and restricting dietary sodium

4. Close Follow Up

   1. Educate patients about:

      1. Disease process

      2. Dietary and pharmacologic treatments

      3. Monitoring weight, symptoms and BP

      4. When to seek care

   2. Periodic telephone follow up between office visits1

Category: Cardiology Notes