cardiovascular disorders
Heart Failure (HF)
Treatment of Heart Failure
Diet and lifestyle changes Treatment of cause Drug therapy Sometimes device therapy (eg, implantable cardioverter-defibrillator, cardiac resynchronization therapy, mechanical circulatory support) Sometimes cardiac transplantation Multidisciplinary care Immediate inpatient treatment is required for patients with acute or worsening heart failure due to certain disorders (eg, Acute Myocardial Infarction (MI) , The primary goal is to diagnose and to correct or treat the disorder that led to heart failure. include relieving symptoms and improving hemodynamics; avoiding Hypokalemia , renal dysfunction, and symptomatic hypotension; and correcting neurohumoral activation. include correcting Hypertension , preventing Treatment involves dietary and lifestyle changes, Drugs for Heart Failure , devices, and sometimes percutaneous coronary interventions or surgery. Treatment is tailored to the patient, considering causes, symptoms, and response to drugs, including adverse effects. There are currently several evidence-based therapies for chronic HFrEF ( Treatment references , Drugs for Heart Failure None General measures,especially patient and caregiver education and diet and lifestyle modifications, are important for all patients with heart failure. Education Sodium restriction Appropriate weight and fitness levels Correction of underlying conditions Patient and caregiver education are critical to long-term success. The patient and family should be involved in treatment choices. They should be taught the importance of drug adherence, warning signs of an exacerbation, and how to link cause with effect (eg, increased salt in the diet with weight gain or symptoms). Many centers (eg, specialized outpatient clinics) have integrated health care practitioners from different disciplines (eg, HF nurses, pharmacists, social workers, rehabilitation specialists) into multidisciplinary teams or outpatient heart failure management programs. These approaches can improve outcomes and reduce hospitalizations and are most effective in the sickest patients. Dietary sodium restrictionhelps limit fluid retention. All patients should eliminate salt in cooking and at the table and avoid salted foods; the most severely ill should limit sodium to<2 g/day by consuming only low-sodium foods. Monitoring daily morning weighthelps detect sodium and water accumulation early. If weight increases>2 kg over a few days, patients may be able to adjust their diuretic dose themselves, but if weight gain continues or symptoms occur, patients should seek medical attention. Intensive case management,particularly by monitoring drug adherence and frequency of unscheduled visits to the physician or emergency department and hospitalizations, can identify when intervention is needed. Specialized HF nurses are valuable in education, follow-up, and dosage adjustment according to predefined protocols. Patients with atherosclerosis or diabetes should strictly follow a diet appropriate for their disorder. Obesity may cause and always aggravates the symptoms of HF; patients should attain a body mass index (BMI) ≤ 30 kg/m2(ideally 21 to 25 kg/m2). (eg, walking), tailored to symptoms, is generally encouraged. Activity prevents skeletal muscle deconditioning, which worsens functional status; however, activity does not appear to improve survival or decrease hospitalizations. Rest is appropriate during acute exacerbations. Formal exercise Cardiovascular Rehabilitation is useful for chronic HFrEF and is likely helpful for patients with HFpEF. Patients should have annual Influenza Vaccine because influenza can precipitate HF exacerbations, particularly in institutionalized or older patients. Patients should be vaccinated against SARS-CoV-2. If causes such as hypertension, persistent tachyarrhythmia, severe anemia, hemochromatosis, uncontrolled diabetes, thyrotoxicosis, beriberi, alcohol use disorder, or toxoplasmosis are successfully treated, patients may dramatically improve. Significant myocardial ischemia should be treated aggressively; treatment may include revascularization by Percutaneous coronary intervention (PCI) or Because arrhythmias can worsen heart failure, it is important to identify and treat the cause of any Overview of Arrhythmias . Electrolytes are normalized. Atrial and ventricular rates are controlled. Sometimes antiarrhythmic drugs are given. Sinus tachycardia, a common compensatory change in heart failure, usually subsides when HF treatment is effective. If it does not, associated causes (eg, Hyperthyroidism , Atrial Fibrillation with an uncontrolled ventricular rate must be treated; the target resting ventricular rate is typically Isolated Ventricular Premature Beats (VPB) , which are common in HF, do not require specific treatment, although rarely very frequent ventricular premature beats (> 15,000/day) have been shown to precipitate heart failure (that reverses with suppression). However, optimization of HF treatments and correction of electrolyte abnormalities (especially potassium and magnesium) reduce the risk of ventricular arrhythmias. Sustained Ventricular Tachycardia (VT) that persists despite correction of cause (eg, low potassium or magnesium, ischemia) and optimal medical treatment of HF may require an Use of an Implantable Cardioverter-Defibrillators (ICD) (ICD) or 35% while receiving guideline-directed medical therapy. The data for ICD use in HFrEF are stronger for ischemic cardiomyopathy than in nonischemic cardiomyopathy. A clinical trial that included HFrEF patients with nonischemic cardiomyopathy demonstrated no mortality benefit from prophylactic (primary prevention) ICD placement ( Treatment references ). CRTis a mode of pacing that synchronizes contraction of the left ventricle by simultaneously pacing its opposing wall, thereby improving stroke volume. CRT may relieve symptoms and reduce heart failure hospitalizations for patients who have HF, LVEF<35%, and a widened QRS complex with a left bundle branch block pattern (>0.15 second—the wider the QRS, the greater potential benefit). CRT devices are effective but expensive, and patients should be appropriately selected. Many CRT devices also incorporate an ICD in their mechanism. An implantable device that remotely monitors invasive hemodynamics (eg, pulmonary artery pressure) may help guide heart failure management in highly selected patients. For example, drug (eg, diuretic) titration based on readings from one of these devices was associated with a marked reduction in HF hospitalization in one clinical trial that included patients with both HFrEF and HFpEF. The device uses the pulmonary artery diastolic pressure as a surrogate for pulmonary capillary wedge pressure (and hence left atrial pressure) in HF patients. However, it has been evaluated only in NYHA (New York Heart Association) class III patients who had recurrent HF exacerbations. Further evidence will help guide how this technology should be implemented. Ultrafiltration(venovenous filtration) can be useful in selected hospitalized patients with severe cardiorenal syndrome and volume overload refractory to diuretics. However, ultrafiltration should not be used routinely because clinical trials do not show long-term clinical benefit. Anintra-aortic counterpulsation balloon pump(IABP) is helpful in selected patients with acute HF who have a good chance of recovery (eg, acute HF following myocardial infarction) or in those who need a bridge to a more permanent solution such as cardiac surgery (eg, to fix severe valvular disease or to revascularize multivessel coronary artery disease), an LV assist device, or heart transplantation. Other forms of temporary mechanical circulatory support for patients with acute HF and cardiogenic shock include surgically placed devices such asextracorporeal membrane oxygenation(ECMO, typically venoarterial cannulation) andcentrifugal flow ventricular assist devicesthat can support either the LV, the RV, or both and can also be combined with an oxygenator to provide full cardiopulmonary support. Percutaneously placed devices such asintravascular microaxial ventricular assist devicesare available for both LV and RV support. Selection of temporary mechanical circulatory support devices is based mainly on availability and local medical center experience. Durable or ambulatoryLV assist devices(LVADs) are longer-term implantable pumps that augment LV output. They are commonly used to maintain patients with severe HF who are awaiting transplantation and are also used as "destination therapy" (ie, as a long-term or permanent solution) in some patients who are not transplant candidates. Surgery may be appropriate when certain underlying disorders are present. Surgery in patients with advanced HF should be done in a specialized center. Surgical closure of congenital or acquired intracardiac shunts can be curative. Coronary artery bypass grafting (CABG) (CABG) for patients with LV systolic dysfunction secondary to coronary artery disease and evidence of myocardial viability may be beneficial; however, those patients with prior myocardial infarction and non-viable myocardium are less likely to benefit from CABG. Thus, the decision to revascularize a HF patient with multivessel coronary artery disease should be made on a case-by-case basis. If HF is primarily due to a Overview of Cardiac Valvular Disorders , valve repair or replacement should be considered. Patients with primary mitral regurgitation are more likely to benefit than patients with mitral regurgitation secondary to LV dilation, in whom poor myocardial function is likely to continue postoperatively. Surgery is preferably done before myocardial dilation and damage become irreversible. More recently, percutaneous mitral valve repair procedure (also called transcatheter end-to-end repair [TEER]), in which a clip is applied to approximate the anterior and posterior mitral leaflets, has been shown to reduce death and HF hospitalization in carefully selected patients with symptomatic HF despite optimal medical management and moderate to severe or severe mitral regurgitation with preserved LV size (end-systolic dimension ≤ 70 mm— Heart Transplantation is the treatment of choice for patients Anemia is common among patients with chronic heart failure and is frequently multifactorial. Anemia is associated with worse symptoms and outcomes in HF and so reversible causes should be sought and treated. Iron Deficiency Anemia is among the most common causes of anemia in HF, and iron replacement therapy should be considered once treatable causes such as blood loss (gastrointestinal or other) have been excluded. Oral iron replacement is often less effective due to poor absorption and other reasons, thus intravenous iron replacement is preferred. After treatment, symptoms often persist. Reasons include Persistence of the underlying disorder (eg, hypertension, ischemia/infarction, valvular disease) despite treatment Suboptimal treatment of heart failure Drug nonadherence Excess intake of dietary sodium or alcohol Presence of an undiagnosed thyroid disorder, anemia, or supervening arrhythmia (eg, atrial fibrillation with rapid ventricular response, intermittent ventricular tachycardia) Also, drugs used to treat other disorders may interfere with HF treatment. Nonsteroidal anti-inflammatory drugs (NSAIDs), thiazolidinediones (eg,pioglitazone) for diabetes, and short-acting dihydropyridine or nondihydropyridine calcium channel blockers can worsen heart failure and should be avoided unless no alternative exists; patients who must take such drugs should be followed closely. 1.McDonagh TA, Metra M, Adamo M, et al: 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) with the special contribution of the Heart Failure Association (HFA) of the ESC.Eur Heart J42(36):3599-3726, 2021. doi: 10.1093/eurheartj/ehab368 2.Heidenreich PA, Bozkurt B, Aguilar D, et al: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.Circulation145:e876–e894, 2022, doi: 10.1161/CIR.0000000000001062 3.Shah SJ, Kitzman D, Borlaug B, et al: Phenotype-specific treatment of heart failure with preserved ejection fraction: A multiorgan roadmap.Circulation134(1):73–90, 2016. doi: 10.1161/CIRCULATIONAHA.116.021884 4.Kober L, Thune JJ, Nielsen JC, et al: Defibrillator implantation in patients with nonischemic systolic heart failure.N Engl J Med375(13):1221–2130, 2016. doi: 10.1056/NEJMoa1608029 5.Stone GW, Lindenfield J, Abraham WT, et al: Transcatheter mitral-valve repair in patients with heart failure.N Engl J Med379(24):2307–2318, 2018. doi: 10.1056/NEJMoa1806640 