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The treatment of CHF focuses on treating the symptoms and signs of CHF and preventing the progression of disease. If there is a reversible cause of the heart failure (e.g. infection, alcohol ingestion, anemia, thyrotoxicosis, arrhythmia, or hypertension), that should be addressed as well. Reversible cause treatments can include exercise, eating healthy foods, reduction in salty foods, and abstinence of smoking and drinking alcohol.
Non-pharmacological measures
Patients with CHF are educated to undertake various non-pharmacological measures to improve symptoms and prognosis. Such measures include (Smith et al., 2003):
* Moderate physical activity, when symptoms are mild or moderate; or bed rest when symptoms are severe.
* Weight reduction – through physical activity and dietary modification, as obesity is a risk factor for heart failure and ventricular hypertrophy.
* Sodium restriction – excessive sodium intake may precipitate or exacerbate heart failure, thus a "no added salt" diet (60–100 mmol total daily intake) is recommended for patients with CHF. More severe restrictions may be required in severe CHF.
* Fluid restriction – patients with CHF have a diminished ability to excrete free water load. They are also at an increased risk of hyponatremia due to the combination of decreased sodium intake and diuretic therapy. Generally water intake should be limited to 1.5 L daily or less in patients with hyponatremia, though fluid restriction may be beneficial regardless in symptomatic reduction.
* Certain drugs can exacerbate HF and should be avoided: antiarrhythmic agents (with some exceptions); calcium channel blockers and first generation dihydropyridine; non-steroidal anti-inflammatory drugs, coxibs, and corticosteroids; and tricyclic antidepressants and lithium.
Pharmacological management
There is a significant evidence–practice gap in the treatment of CHF; particularly the underuse of ACE inhibitors and ?-blockers and aldosterone antagonists which have been shown to provide mortality benefit. (Jackson et al., 2005) Treatment of CHF aims to relieve symptoms, maintain a euvolemic state (normal fluid level in the circulatory system), and to improve prognosis by delaying progression of heart failure and reducing cardiovascular risk. Drugs used include: diuretic agents, vasodilator agents, positive inotropes, ACE inhibitors, beta blockers, and aldosterone antagonists (e.g. spironolactone). It should be noted that while intuitive, increasing heart function with some drugs, such as the positive inotrope Milrinone, leads to increased mortality.
Angiotensin-modulating agents
ACE inhibitor (ACE) therapy is a for all patients with systolic heart failure, irrespective of symptomatic severity or blood pressure. (NICE, 2003) ACE inhibitors improve symptoms, decrease mortality and reduce ventricular hypertrophy. Angiotensin II receptor antagonist therapy (also referred to as AT1-antagonists or angiotensin receptor blockers), particularly using candesartan, is an acceptable alternative if the patient is unable to tolerate ACEI therapy.
Diuretics
Diuretic therapy is indicated for relief of congestive symptoms. Several classes are used, with combinations reserved for severe heart failure (Smith et al., 2003):
* Loop diuretics (e.g. furosemide) – most commonly used class in CHF, usually for moderate CHF.
* Thiazide diuretics (e.g. hydrochlorothiazide) – useful for mild CHF.
* Potassium-sparing diuretics (e.g. amiloride) – used first-line use to correct hypokalaemia.
o Spironolactone is used as add-on therapy to ACEI plus loop diuretic in severe CHF.
o Eplerenone is specifically indicated for post-MI reduction of cardiovascular risk.
Beta blockers
Until recently, ?-blockers were contraindicated in CHF, owing to their negative inotropic effect and ability to produce bradycardia – effects which worsen heart failure. However, current guidelines recommend ?-blocker therapy for patients with systolic heart failure due to left ventricular systolic dysfunction after stabilization with diuretic and ACEI therapy, irrespective of symptomatic severity or blood pressure. (NICE, 2003) As with ACEI therapy, the addition of a ?-blocker can decrease mortality and improve left ventricular function. Several ?-blockers are specifically indicated for CHF including: bisoprolol, carvedilol, and extended-release metoprolol.
Positive inotropes
Digoxin, once used as first-line therapy, is now reserved for control of ventricular rhythm in patients with atrial fibrillation; or where adequate control is not achieved with ACEI plus loop diuretic. There is no evidence that positive inotropes reduce mortality in CHF.it is contraindicated in cardiac tamponade and restrictive cardiomyopathy
[edit] Alternative vasodilators
The combination of isosorbide dinitrate/hydralazine is the only vasodilator regimen, other than ACE inhibitors or angiotensin II receptor antagonists, with proven survival benefits. This combination appears to be particularly beneficial in CHF patients with an African American background, who respond less effectively to ACEI therapy.
Aldosterone Receptor Antagonists
For patients with advanced HF (EF?35-40%, NYHA III-IV) should be treated with aldosterone receptor antagonists in addition to standard treatment options (unless risk of contraindication. Results from the RALES and EPHESUS trials show that aldosterone receptor antagonists decrease mobidity and mortality in this patient group.[12]
Devices and surgery
Patients with NYHA class III or IV, left ventricular ejection fraction (LVEF) of 35% or less and a QRS interval of 120 ms or more may benefit from cardiac resynchronization therapy (CRT; pacing both the left and right ventricles), through implantation of an bi-ventricular pacemaker, or surgical remodelling of the heart. These treatment modalities may make the patient symptomatically better, improving quality of life and in some trials have been proven to reduce mortality.
The COMPANION trial demonstrated that CRT improved survival in individuals with NYHA class III or IV heart failure with a widened QRS complex on EKG. The CARE-HF trial showed that patients receiving CRT and optimal medical therapy benefited from a 36% reduction in all cause mortality, and a reduction in cardiovascular-related hospitalization.
Patients with NYHA class II, III or IV, and LVEF of 35% (without a QRS requirement) may also benefit from an implantable cardioverter-defibrillator (ICD), a device that is proven to reduce all cause mortality by 23% compared to placebo. This mortality benefit was observed in patients who were already optimally-managed on drug therapy.
Another current treatment involves the use of left ventricular assist devices (LVADs). LVADs are battery-operated mechanical pump-type devices that are surgically implanted on the upper part of the abdomen. They take blood from the left ventricle and pump it through the aorta. LVADs are becoming more common and are often used by patients who have to wait for heart transplants.
The final option, if other measures have failed, is cardiac transplant surgery (heart transplant) or implantation of an artificial heart.
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Important notice:
The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other
qualified health provider with any questions you may have regarding a medical condition.
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