Drug treatment of heart failure due to left ventricular systolic dysfunction is covered below; optimal management of heart failure with preserved left ventricular function is not established.
The treatment of chronic heart failure aims to relieve symptoms, improve exercise tolerance, reduce the incidence of acute exacerbations, and reduce mortality. An ACE inhibitor, titrated to a ‘target dose’ (or the maximum tolerated dose if lower), and a beta-blocker is recommended to achieve these aims. A diuretic is also necessary in most patients to reduce symptoms of fluid overload.
An ACE inhibitor is generally advised for patients with asymptomatic left ventricular dysfunction or symptomatic heart failure. An angiotensin-II receptor antagonist may be a useful alternative for patients who, because of side-effects such as cough, cannot tolerate ACE inhibitors; a relatively high dose of the angiotensin-II receptor antagonist may be required to produce benefit.
The beta-blockers bisoprolol and carvedilol are of value in any grade of stable heart failure and left-ventricular systolic dysfunction; nebivolol is licensed for stable mild to moderate heart failure in patients over 70 years. Beta-blocker treatment should be started by those experienced in the management of heart failure, at a very low dose and titrated very slowly over a period of weeks or months. Symptoms may deteriorate initially, calling for adjustment of concomitant therapy.
Patients with fluid overload should also receive either a loop or a thiazide diuretic (with salt or fluid restriction where appropriate). A thiazide diuretic may be of benefit in patients with mild heart failure and good renal function; however, thiazide diuretics are ineffective in patients with poor renal function (estimated creatinine clearance less than 30 mL/minute, see Appendix 3) and a loop diuretic is preferred. If diuresis with a single diuretic is insufficient, a combination of a loop diuretic and a thiazide diuretic may be tried; addition of metolazone may also be considered but the resulting diuresis may be profound and care is needed to avoid potentially dangerous electrolyte disturbances.
The aldosterone antagonist spironolactone can be considered for patients with moderate to severe heart failure who are already taking an ACE inhibitor and a beta-blocker; low doses of spironolactone (usually 25 mg daily) reduce symptoms and mortality in these patients. If spironolactone cannot be used, eplerenone may be considered for the management of heart failure after an acute myocardial infarction with evidence of left ventricular dysfunction. Close monitoring of serum creatinine and potassium is necessary with any change in treatment or in the patient’s condition.
Digoxin improves symptoms of heart failure and exercise tolerance and reduces hospitalisation due to acute exacerbations but it does not reduce mortality. Digoxin is reserved for patients with atrial fibrillation and also for selected patients in sinus rhythm who remain symptomatic despite treatment with an ACE inhibitor, a beta-blocker, and a diuretic.
Patients who cannot tolerate an ACE inhibitor or an angiotensin-II receptor antagonist, or in whom they are contra-indicated, may be given isosorbide dinitrate with hydralazine but this combination may be poorly tolerated. In African-American patients, the combination of isosorbide dinitrate and hydralazine may be considered in addition to standard therapy if necessary.
The treatment of chronic heart failure aims to relieve symptoms, improve exercise tolerance, reduce the incidence of acute exacerbations, and reduce mortality. An ACE inhibitor, titrated to a ‘target dose’ (or the maximum tolerated dose if lower), and a beta-blocker is recommended to achieve these aims. A diuretic is also necessary in most patients to reduce symptoms of fluid overload.
An ACE inhibitor is generally advised for patients with asymptomatic left ventricular dysfunction or symptomatic heart failure. An angiotensin-II receptor antagonist may be a useful alternative for patients who, because of side-effects such as cough, cannot tolerate ACE inhibitors; a relatively high dose of the angiotensin-II receptor antagonist may be required to produce benefit.
The beta-blockers bisoprolol and carvedilol are of value in any grade of stable heart failure and left-ventricular systolic dysfunction; nebivolol is licensed for stable mild to moderate heart failure in patients over 70 years. Beta-blocker treatment should be started by those experienced in the management of heart failure, at a very low dose and titrated very slowly over a period of weeks or months. Symptoms may deteriorate initially, calling for adjustment of concomitant therapy.
Patients with fluid overload should also receive either a loop or a thiazide diuretic (with salt or fluid restriction where appropriate). A thiazide diuretic may be of benefit in patients with mild heart failure and good renal function; however, thiazide diuretics are ineffective in patients with poor renal function (estimated creatinine clearance less than 30 mL/minute, see Appendix 3) and a loop diuretic is preferred. If diuresis with a single diuretic is insufficient, a combination of a loop diuretic and a thiazide diuretic may be tried; addition of metolazone may also be considered but the resulting diuresis may be profound and care is needed to avoid potentially dangerous electrolyte disturbances.
The aldosterone antagonist spironolactone can be considered for patients with moderate to severe heart failure who are already taking an ACE inhibitor and a beta-blocker; low doses of spironolactone (usually 25 mg daily) reduce symptoms and mortality in these patients. If spironolactone cannot be used, eplerenone may be considered for the management of heart failure after an acute myocardial infarction with evidence of left ventricular dysfunction. Close monitoring of serum creatinine and potassium is necessary with any change in treatment or in the patient’s condition.
Digoxin improves symptoms of heart failure and exercise tolerance and reduces hospitalisation due to acute exacerbations but it does not reduce mortality. Digoxin is reserved for patients with atrial fibrillation and also for selected patients in sinus rhythm who remain symptomatic despite treatment with an ACE inhibitor, a beta-blocker, and a diuretic.
Patients who cannot tolerate an ACE inhibitor or an angiotensin-II receptor antagonist, or in whom they are contra-indicated, may be given isosorbide dinitrate with hydralazine but this combination may be poorly tolerated. In African-American patients, the combination of isosorbide dinitrate and hydralazine may be considered in addition to standard therapy if necessary.
very good article....
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