Helping the failing heart:
Safe and effective CHF management.
Six million Americans suffer from congestive heart failure, leading to one million hospitalizations a year.
One in five patients with CHF are readmitted within 30 days.
Is the patient’s CHF primarily systolic or diastolic?
- Often hard to tell apart based on clinical exam alone.
- Echocardiogram can help differentiate.
- Mortality rates are similar.
- Different causes, patient demographics, and evidence-based management.
Non-drug interventions: recommended for all CHF patients
- Fluid restriction of 1-2 L/day, depending on edema and symptoms
- Daily weights: same scale, same time, every day
- Exercise (safe for most CHF patients)
- Quit smoking, and drink alcohol only in moderation
- Sodium restriction to 2-4 grams/day. Patients should:
- not add salt to meals
- shun canned foods
- avoid eating out, especially fast food
- learn how to identify sodium content on food labels
Managing acute decompensated CHF
Assess for the most common triggers for decompensation:
- cardiac (progressive disease, new ischemia – including a new infarct , hypertension, arrhythmia, or valvular problem)
- non-compliance (with medications, or with salt/fluid restriction)
- new or worsening co-morbid condition (renal or liver dysfunction, thyroid abnormality, infection, anemia).
Generally, continue the patient’s usual medications and titrate up or down depending on:
- vital signs
- lab tests
- clinical stability.
Aggressive therapies such as inotropes, vasodilators, and natriuretic peptides do not reduce mortality, and generally be reserved for critically ill patients.
Ultra-filtration and non-invasive positive pressure ventilation are both beneficial, but may not be locally available.
When conservative measures are inadequate, invasive therapies may be required.
- revascularization by CABG or multi-vessel PCI in patients with symptomatic ischemia
- valve surgery in patients with significant stenosis or regurgitation
- cardiac resynchronization therapy in patients with symptomatic systolic CHF and QRS>120 msec
- implantable cardiac defibrillators in those at risk for sudden cardiac death (EF<35% on maximal medical therapy with expected life >1 year)
When CHF is a terminal illness
In patients with Class IV CHF symptoms despite maximal medical therapy, discuss their preferences for end of life care, including:
- information on how to prepare a medical power of attorney, living will, and “do not resuscitate” orders, if desired;
- perspectives on the utility vs. futility of invasive management at the end of life (e.g., ICU care, ventilator, resuscitation);
- symptomatic therapy for dyspnea and other symptoms;
- options concerning hospice care at home or in a facility;
- decisions about inactivating an ICD (if present).
Summary of evidence-based treatments
- All ACE inhibitors benefit systolic CHF, and are generally similar; titrate dose to lowest tolerated blood pressure
- use ARBs for ACE-intolerant patients
- Beta-blockers benefit systolic CHF; titrate to lowest tolerated heart rate
- proven agents include carvedilol, bisoprolol, metoprolol XL/CR
- Aldosterone antagonists benefit systolic CHF
- proven agents: spironolactone and eplerenone
- Digoxin reduces hospitalizations in systolic CHF
- renally excreted
- dose carefully to avoid toxicity, especially in older patients
- Loop diuretics are first-line drugs to control edema
- combine with a thiazide or potassium-sparing diuretic for additional diuresis
- Hydralazine + isosorbide dinitrate can be added to improve persistent symptoms in systolic CHF
- Unsaturated fatty acids are beneficial and well tolerated
- Useful treatments for diastolic CHF include beta blockers, ACEIs (or ARBs), and diuretics.
- but there is little evidence of benefit in diastolic CHF from aldosterone antagonists, digoxin, or hydralazine + isorsorbide dinitrate.
Counsel all CHF patients on lifestyle changes that can improve control of their symptoms.
