Treatment and Management of Heart Failure
For people who develop heart failure, the underlying
cause and the severity of symptoms will determine
what happens next. For most people, managing
heart failure requires a combination of taking
daily medications, eating
less salt, limiting fluids and making other lifestyle
modifications. In some cases, angioplasty
or surgery may be necessary.
Finally, other therapies, such as special assistive devices, may be needed.
Although in the past, the prognosis for people
with heart failure was poor, current medications
and devices have significantly improved both
survival and symptoms. For this reason, it is
critical that people with heart failure continue
to take their medications even if they feel well,
as these medications can continue to stabilize
and even strengthen the heart muscle over time.
Medications for Heart Failure
Currently, there are five major groups of medications
that doctors use to help people with heart failure.
Your doctor may need to make several adjustments
in order to find the right combination of medications
to help you feel better with the fewest number
of side effects.
Vasodilators
The first group of medications is vasodilators. Vasodilators work by relaxing
the blood vessels, making it easier for the heart to pump blood to the body.
As more blood is able to get to the kidneys, more urine is produced, and less
fluid accumulates in the body.
The mainstay of this group includes medications
known as ACE
inhibitors. In many studies of patients with
heart failure, ACE inhibitors have been shown
to improve symptoms and decrease the risk of
dying. Common side effects of ACE inhibitors
include lightheadedness, very low blood pressure
and, occasionally, a dry cough. Your doctor may
want to perform blood tests after you start an
ACE inhibitor to check electrolytes and kidney
function. Non-steroidal anti-inflammatory drugs
(NSAIDs), such as ibuprofen or naproxen sodium,
may interfere with the action of ACE inhibitors
and may make it difficult for the kidneys to
make urine. It is important to check with your
doctor before taking these over-the-counter medications.
Angiotensin receptor blockers (ARB) are another
class of vasodilator medications that are very
closely related to ACE inhibitors. This class
of drugs has also been studied in heart failure
patients and is an excellent choice in people
who develop a cough when taking ACE Inhibitors.
Recent studies have also shown that adding an
ARB to an ACE inhibitor may be beneficial for
some people with heart failure. Common side effects
of ARB include lightheadedness and very low blood
pressure.
The final vasodilating medication is a combination
of hydralizine and isosorbide dinitrate (or mononitrate).
In a recent study of African Americans with heart
failure the combination of hydralizine and isosorbide
dinitrate, in addition to an ACE inhibitor and
beta blocker, improved symptoms and survival.
This combination is also useful in any person
with kidney dysfunction who may not be able to
safely take an ACE inhibitor or ARB. Side effects
of hydralizine/isosorbide dinitrate include lightheadedness,
headache that resolves after a few days, very
low blood pressure and, occasionally, a rash
and joint pains.
Beta-blockers
The second class of drugs approved to treat heart failure is beta-blockers. Beta-blockers
have been used for many years in the treatment of other types of heart disease.
Over the past several years, many studies have shown that beta-blockers may
improve symptoms and lengthen the lives of people with heart failure. Beta-blockers
rarely make people feel slightly worse for a few days when they are first started.
After this initial period has passed, most people feel better. Beta-blockers
can help people from very mild heart failure to the most severe heart failure
and overtime are the most powerful class of medications that can strengthen
the heart.
The most common side effects of beta-blockers
include lightheadedness, worsening symptoms of
heart failure and a slow heart rate. Monitoring
your weight very closely when first starting
or increasing the dose of a beta blocker is useful
in detecting increased fluid accumulation that
rarely can occur. It is very important not to
stop a beta-blocker suddenly as serious side-effects
can occur. You should discuss any changes in
your medications, including any problems getting
or affording your medications with your physician.
Diuretics
The next group of drugs is diuretics. These drugs are commonly referred to
as "water pills" because they force the kidneys to make more urine.
In heart failure, the kidneys are fooled into believing that the body is dehydrated.
This occurs because the amount of blood pumped from the heart to the kidneys
is reduced due to heart failure. The kidneys respond to this decreased blood
flow by retaining salt and water and decreasing urine production. In addition,
the kidneys produce hormones that make people with heart failure feel thirsty.
The extra fluid that is retained by the kidneys will eventually put an additional
strain on the weakened heart and lead to fluid collecting in the lungs, abdomen,
ankles or hands. Diuretics force the kidneys to make more urine and to remove
excess water and salt from the body. As a result, diuretics help control swelling
and shortness of breath. In combination with an ACE inhibitor, a diuretic can
help provide good control over the symptoms of heart failure.
The most common diuretic used in heart failure
is furosemide (Lasix). The common side effects
of diuretics include lightheadedness and low
electrolyte levels in the blood. Many people
who take diuretics need to take additional potassium,
which is an electrolyte in the blood. Potassium
levels that are too high or too low can be dangerous.
Your doctor may want to check your electrolytes
and adjust your medications as needed.
Another diuretic called spironolactone (Aldactone)
has been shown to improve the symptoms and life
expectancy for people with heart failure. This
medication was only shown to be effective in
people with moderate to severe heart failure
and who had normal kidney function and electolytes.
Spironolactone is known to cause the amount of
potassium in the blood to rise. For this reason
your doctor will want to check the electrolytes
in your blood after beginning this medication.
In men, spironolactone can occasionally cause
a painful swelling of the breasts.
Digoxin
Digoxin is a medication derived from the foxglove plant. It has several effects
on the body, but is thought to help the heart squeeze harder. Digoxin is only
used for people who continue to have symptoms of heart failure despite being
on vasodilators, beta blockers and diuretics. The common side effects of digoxin
include irregular or slow heartbeats, nausea and loss of appetite. Your doctor
will want to monitor the level of digoxin in your blood stream periodically.
Digoxin can interact with many prescription, over-the-counter and herbal medications
that can lead to dangerously high digoxin levels.
Blood thinners
The next group of drugs is blood thinners. These drugs can reduce the risk of
stroke for heart failure patients. When the heart is not functioning normally
and the amount of blood pumped in each beat is decreased, small blood clots can
develop inside the heart. Occasionally, one of these blood clots may leave the
heart and travel to the brain, where it can cause a stroke. The risk of forming
clots in the heart is increased if the heartbeat is irregular or if there is
valve disease.
The common blood thinners include warfarin (Coumadin)
and aspirin. Warfarin requires frequent blood
test to ensure that blood is neither too thick
nor too thin. Both aspirin and warfarin can increase the risk of bleeding.
It's important to discuss the risks and benefits
of warfarin or aspirin therapy with the doctor.
Warfarin (Coumadin) has many drug interactions
including over the counter and herbal medications.
These
interactions can make the blood dangerously
thin increasing the risk of bleeding or can inactivate
warfarin and increase the risk of stroke. It
is very important to check with your doctor,
nurse or pharmacist before taking any new medications
if you are taking warfarin (Coumadin).
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Lifestyle Modifications
In addition to the common therapies for heart
failure, there are things you can do on your
own to help protect your health.
Your doctor may ask you to weigh yourself
daily. Sudden weight gain of a few pounds
over one to two days may signal that your body
is retaining excess fluid, even if you feel
fine. Your doctor may want to adjust your medications
and may remind you to watch the salt in your
diet to prevent your symptoms from getting
worse.
Following a low-salt diet can help to
prevent fluid buildup and keep you feeling good.
Salt intake should be limited to 2,000 mg, or
about 1 teaspoonful per day. Many foods have
hidden salt, especially canned, prepared or processed
foods. Talk to your doctor about which foods
you should avoid to keep your salt intake down.
When heart failure occurs, the body produces
many hormones to help compensate for the decreased
blood flow. These hormones cause some of the
symptoms that heart failure patients experience.
For example, people with heart failure often
feel thirsty due to the overproduction of one
hormone. However, it's important not to replace
the fluid that diuretics have helped to remove.
Many doctors recommend that patients limit
their fluid intake to a total of about 8 glasses
each day.
Losing weight will make it easier for
the heart to pump blood to the body. Quitting
smoking is essential. Smoking puts additional
strain on the heart and can lead to blockages
in the arteries supplying blood to the heart
muscle. In addition, if you have had CABG or
angioplasty, smoking increases the risk that
the arteries will block up again. Smoking also
injures the lungs. When the heart is weak, the
other organs need to help compensate. If you
have weak lungs, it's more difficult for your
heart to pump efficiently. This can make shortness
of breath much worse.
If you're suffering from heart failure, you
should get a flu shot every year and have
a pneumovax, (pneumonia vaccine) at least once.
The flu can make people with heart failure critically
ill, so you also may want to stay away from people
who have colds or the flu.
Regular, low-level exercise can improve
heart function over time and help you feel better.
Avoid strenuous exercise and lifting heavy objects
so as not to place a sudden strain on your heart.
Participating in a structured cardiac rehabilitation
program can help you learn to exercise
safely. People who have participated in these
programs often feel better and learn how to
manage their heart failure. Most cardiac rehabilitation
programs can help with exercise, diet, quitting
smoking, stress reduction and weight reduction.
Cardiac rehabilitation programs also can provide
support groups and referrals to other resources
in the community.
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Electrical Devices for Heart Failure
For people who continue to have symptoms of
heart failure despite medications and lifestyle
changes, specialized pacemakers call biventricular
pacemakers can be placed by a specially trained
cardiologist. These permanently placed devices
can help the right and left sides of the heart
work in a more coordinated way. These pacemakers
have been shown to improve symptoms, strengthen
the heart and improve length of life. Not everyone
with heart failure will benefit from this device,
so it is important to discuss whether you are
a good candidate with your doctor.
Many people with heart failure are at risk of
developing a sudden irregular heartbeat (arrhythmia)
that can lead to sudden death. Recent studies
have shown that when the heart squeeze is moderately
or severely weakened, the placement of an automatic
implantable defibrillator (AICD) may prevent
sudden death. If a dangerous arrhythmia is detected,
the device will deliver a small electric shock
to return the heart to a more normal rhythm.
The placement of an AICD will not make a person
feel any better but is considered an “insurance
policy” against sudden death. AICD can
be combined with a biventricular pacemaker in
a single device.
People with AICD and pacemakers of any type will
have a few restrictions. Very strong magnetic fields,
like from an MRI scanner can interfere with the
functioning of these devices. For this reason,
people with pacemakers or AICD may not have an
MRI. Most common appliances and devices encountered
in everyday life, like microwave ovens, telephones
or audiovisual equipment are safe for people with
pacemakers or AICD. Pacemakers or AICD can trigger
metal detector devices as part of security screening
check points. Carrying a note from your doctor
and requesting a manual search is often all that
is required.
Angioplasty for Heart Failure
In people with coronary
artery disease, restoring blood flow to
the heart can sometimes improve the overall
heart function. In addition, it may help to
prevent future heart attacks. One approach
to restoring blood flow to the heart is a procedure
known as angioplasty.
In the cardiac
catheterization laboratory, a specially
trained cardiologist inserts a small balloon
inside the coronary artery in the area that
is blocked. Once in position, the balloon is
inflated, stretching the artery and allowing
more blood flow.
This procedure is most useful for people who have
only a few blockages. The advantages of angioplasty
are that it does not require surgery, and people
usually spend only a few days in the hospital.
The disadvantage is that blockages may reoccur,
leading to a return of symptoms and the need for
another angioplasty.
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Surgery for Heart Failure
 If heart failure is due to blockages in the
coronary arteries or disease of the heart valves,
surgery may help to reduce symptoms and prevent
progression of the disease.
Coronary
artery bypass grafting (CABG) is performed
by a specially trained surgeon. In this procedure,
a segment of vein is typically taken from
the leg, and a small artery from the inside
of the chest is used to make new connections
to the coronary arteries. In this way, severe
blockages can be bypassed, restoring normal
blood flow. CABG is useful for people who
have several blockages and those with weakened
hearts. The advantage of CABG is that the
results usually last for years, but the disadvantage
is that CABG requires open-heart surgery,
several days in the hospital and a few weeks
of recovery at home.
When the heart muscle is severely weakened
and medications are failing to control symptoms
or progression of the disease, the doctor may
consider a heart transplant. Heart transplants
are performed at specialized centers around
the country. A rigorous evaluation process
is undertaken to determine if the rest of the
organs are healthy and strong enough to survive
both the transplant surgery and the powerful
medications given after a transplant.
Cardiac transplantation is not an easy fix
to the problem of heart failure. Following
transplantation, patients must take drugs to
prevent the body from rejecting the newly transplanted
heart. These medications must be taken for
the rest of one's life and can have serious
side effects. In addition, people who have
had transplants have a weakened immune system
and are susceptible to infections. They must
come to the hospital for frequent checkups.
According to the United Network for Organ
Sharing, in the United States, only 2,016 heart
transplants were performed in 2004. Unfortunately,
more than 40,000 people under the age of 65
years could benefit from a transplant.
To learn more about heart transplantation, visit
the Penn
Transplant Center web site.
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Ventricular
Assist Devices
For
people who are determined to be candidates
for a heart transplant or have exhausted all
medical and surgical therapies, a special artificial
heart pump called a left ventricular assist
device (LVAD) can be surgically inserted. These
devices can be used to support circulation
permanently or to allow someone to survive
to receive a heart transplant. The devices
are placed in the abdomen or in the chest with
cables that are connected outside the body
to batteries or a power source.
People can
go home and live a full life with these devices.
In a person with a limited number of other
medical problems but who is not a transplant
candidate, left ventricular assist devices
have been successfully used to permanently
support the heart function.
Only specialized
centers have been approved to use this exciting
technology. LVAD’s have several drawbacks
including infections as well as the need to
learn how to care for the device. Despite these
problems, LVAD’s have been shown to improve
heart failure symptoms and survival. Over the
next several years, improving technology and
experience will define a larger group of people
who may benefit from this exciting new technology.
Choosing a Health Care Provider
A primary care doctor can help manage
all aspects of your medical care. He or she
can refer you to a cardiologist, who
can help to determine the cause of and best
treatment for your heart failure.
The cardiologist should be board-certified,
meaning that he or she has passed a rigorous
test and is qualified to be an expert on heart
conditions.
If evaluation for a heart transplant is required,
your primary care doctor or cardiologist can
refer you to a center that performs transplantation.
It is very important that you feel comfortable
talking to your doctor and health care team about
any concerns you may have. Be sure to get all
of your questions answered, understand how to
take all medications and know when to call your
doctor.
Reviewed by: Lee
R. Goldberg, MD, MPH
Last updated: November 2005
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