Congestive heart failure treatment of patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)

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Initial and Serial Evaluation of the HF Patient
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Patients With a Prior MI
Sudden Cardiac Death Prevention
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Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
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Obstructive Sleep Apnea in the Patient with CHF
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Saleh El Dassouki, M.D. [2]; Lakshmi Gopalakrishnan, M.B.B.S. [3]Mahmoud Sakr, M.D. [4]; Edzel Lorraine Co, D.M.D., M.D. [5]

Overview

Patients who have had an myocardial infarction or evidence of left ventricular remodeling are at considerable risk of developing heart failure even if they do not present with any symptoms of heart failure.[1] Reducing the risk of additional injury and retarding the evolution and progression of LV remodeling is thus very important in considerably decreasing the incidence of heart failure. Initial appropriate measures include those listed as Class 1 recommendations for patients in Stage A.

The use of nutritional supplements in patients with a recent or remote MI with or without LV remodeling has not been proved to reduce the risk of heart failure.[2]

The aldosterone antagonist eplerenone on the other hand has been shown to reduce morbidity and mortality in patients with low ejection fraction and heart failure after an MI that has already been treated with ACEIs and beta blockers.

Patients with an Acute MI

Various procedures such as the infusion of a fibrinolytic agent or the use of percutaneous coronary intervention can reduce the risk of death and development of heart failure in patients who are experiencing an acute MI[3].[4] [5] Administration of beta blockers combined with ACEIs or ARB in patients with acute MI can decrease the risk of reinfarction or death when initiated within days after the ischemic event, especially in patients whose course is complicated by HF; Those drugs can be administered separately,[6] but the neurohormonal blockade achieved by the combination previously mentioned (beta blockers and ACEIs or ARB) has been demonstrated to produce additive benefits.

Patients With History of MI but Normal Left Ventricular Ejection Fraction

A history of MI, even in patients with normal left ventricular ejection fraction should prompt a vigorous treatment of both hypertension and hyperlipidemia, because of their immense benefit in decreasing the risk of further left ventricular dysfunction especially in patients with a prior ischemic event[7].[8] Patient with a recent MI should also be treated with ACEIs and beta blockers,[9] which have been proven to reduce the risk of death when started days or weeks after an ischemic cardiac event. Evidence from 2 other large-scale studies has shown that long term therapy with an ACEI can also decrease the risk of a major cardiovascular event, even when treatment is initiated months or years after MI[6].[10][11].

Patients with Chronic Reduction of Left Ventricular Ejection Fraction but No Symptoms

As previously discussed, long term treatment with an ACEI have been shown to reduce the risk of HF in patients with ischemic cardiac events without left ventricular dysfunction[12]. This is also true in case of asymptomatic patients with reduced left ventricular function, whether due to a remote ischemic injury or to a nonischemic cardiomyopathy. The usage of ARBs in asymptomatic patients with reduced LVEF have not been fully studied yet and has not been implemented in the treatment of those patients. On the other hand, asymptomatic patients with a low EF have benefited from treatment with ARBs according new studies, particularly in patients who cannot tolerate ACEI. Another important agent recommended in the management of patients with a low EF and no symptoms (especially patients with history of CAD) is beta blockers,[13] although adequate controlled clinical trials are lacking to fully support this recommendation.

No data have been obtained to date to recommend Digoxin in asymptomatic patients with reduced LVEF, except in those with Atrial Fibrillation; the reason behind this, is that Digoxin has only a minimal effect on disease progression in symptomatic patients, [14]so it is unlikely that the drug would be beneficial in those with no symptoms. Calcium Channel Blockers are not recommended as well in patients with asymptomatic reduction of LVEF, but they have not been shown to have adverse effects and may be helpful for the management of concomitant conditions such as hypertension. However, the usage of calcium channel blockers with negative inotropic effects in patients with EF below 40% after MI is not recommended. [15]

Patients whose cardiomyopathy is associated with a rapid arrhythmia of supraventricular origin (e.g. atrial flutter or atrial fibrillation) should be closely monitored because such arrhyhmias may contribute to a further impairment of ventricular function and may either induce or exacerbate the development of cardiomyopathy.[16]

Asymptomatic Patients With Valvular Heart Disease

Patients with severe aortic or mitral valve stenosis or insufficiency should be considered for valvular replacement or surgical repair.[17][18] Poor surgical candidates should be considered for TAVI. Long term therapy with vasodilators as hydralazine and nifedipine has not yet been proven to reduce risk of HF or death in long term studies,[19] however patients with severe aortic insufficiency and preserved LV function may benefit from such treatment to minimize structural changes in the ventricle but these drugs are usually poorly tolerated in this setting.[20]There are no trial or long term studies which prove that these vasodilators are beneficial in severe mitral insufficiency.

2022 AHA/ACC/HFSA Heart Failure Guideline/ 2013 ACCF/AHA Guideline/2009 ACC/AHA Focused Update and 2005 Guidelines for the Diagnosis and Management of Heart Failure in the Adult (DO NOT EDIT) [21][22][23]

Management of Stage B: Preventing the Syndrome ofClinical HF in Patients with Pre-HF (DO NOT EDIT) [21][22][23]

Class I
"1. In patients with LVEF ≤40%, ACEi should be used to prevent symptomatic HF and reduce mortality.[12][24][25][26] (Level of Evidence: A) "
"2. In patients with a recent or remote history of MI or ACS, statins should be used to prevent symptomatic HF and adverse cardiovascular events. [27][28][29][30][31] (Level of Evidence: A) "
"3. In patients with a recent MI and LVEF ≤40% who are intolerant to ACEi, ARB should be used to prevent symptomatic HF and reduce mortality. [32] (Level of Evidence: B-R) "
"4.In patients with a recent or remote history of MI or acute coronary syndrome (ACS) and LVEF ≤40%, evidence-based beta blockers should be used to reduce mortality. [33][34][6] (Level of Evidence: B-R) "
"5.In patients who are at least 40 days post-MI with LVEF ≤30% and NYHA class I symptoms while receiving GDMT and have reasonable expectation of meaningful survival for >1 year, an ICD is recommended for primary prevention of sudden cardiac death (SCD) to reduce total mortality. [35] (Level of Evidence: B-R) "
"6.In patients with LVEF ≤40%, beta blockers should be used to prevent symptomatic HF. [34][6] (Level of Evidence: B-R) "
Class III (Harm)
"7. In patients with LVEF <50%, thiazolidinediones should not be used because they increase the risk of HF, including hospitalizations. [36] (Level of Evidence: B-R) "
"8. In patients with LVEF <50%, nondihydropyridine calcium channel blockers with negative inotropic effects may be harmful. [15][37](Level of Evidence: C-LD) "

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References

  1. ↑ Flather MD, Yusuf S, Køber L, Pfeffer M, Hall A, Murray G, Torp-Pedersen C, Ball S, Pogue J, Moyé L, Braunwald E (2000). "Long-term ACE-inhibitor therapy in patients with heart failure or left-ventricular dysfunction: a systematic overview of data from individual patients. ACE-Inhibitor Myocardial Infarction Collaborative Group". Lancet. 355 (9215): 1575–81. PMID 10821360. Retrieved 2011-04-04. Unknown parameter |month= ignored (help)
  2. ↑ Pitt B, Williams G, Remme W, Martinez F, Lopez-Sendon J, Zannad F, Neaton J, Roniker B, Hurley S, Burns D, Bittman R, Kleiman J (2001). "The EPHESUS trial: eplerenone in patients with heart failure due to systolic dysfunction complicating acute myocardial infarction. Eplerenone Post-AMI Heart Failure Efficacy and Survival Study" (PDF). Cardiovascular Drugs and Therapy / Sponsored by the International Society of Cardiovascular Pharmacotherapy. 15 (1): 79–87. PMID 11504167. Retrieved 2011-04-04. Unknown parameter |month= ignored (help)
  3. ↑ Guerci AD, Gerstenblith G, Brinker JA, Chandra NC, Gottlieb SO, Bahr RD, Weiss JL, Shapiro EP, Flaherty JT, Bush DE (1987). "A randomized trial of intravenous tissue plasminogen activator for acute myocardial infarction with subsequent randomization to elective coronary angioplasty". The New England Journal of Medicine. 317 (26): 1613–8. doi:10.1056/NEJM198712243172601. PMID 2960897. Retrieved 2011-04-04. Unknown parameter |month= ignored (help)
  4. ↑ "GISSI-3: effects of lisinopril and transdermal glyceryl trinitrate singly and together on 6-week mortality and ventricular function after acute myocardial infarction. Gruppo Italiano per lo Studio della Sopravvivenza nell'infarto Miocardico". Lancet. 343 (8906): 1115–22. 1994. PMID 7910229. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  5. ↑ "Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. The Acute Infarction Ramipril Efficacy (AIRE) Study Investigators". Lancet. 342 (8875): 821–8. 1993. PMID 8104270. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  6. ↑ 6.0 6.1 6.2 6.3 Vantrimpont P, Rouleau JL, Wun CC, Ciampi A, Klein M, Sussex B, Arnold JM, Moyé L, Pfeffer M (1997). "Additive beneficial effects of beta-blockers to angiotensin-converting enzyme inhibitors in the Survival and Ventricular Enlargement (SAVE) Study. SAVE Investigators". Journal of the American College of Cardiology. 29 (2): 229–36. PMID 9014971. Retrieved 2011-04-04. Unknown parameter |month= ignored (help)
  7. ↑ Kostis JB, Davis BR, Cutler J, Grimm RH, Berge KG, Cohen JD, Lacy CR, Perry HM, Blaufox MD, Wassertheil-Smoller S, Black HR, Schron E, Berkson DM, Curb JD, Smith WM, McDonald R, Applegate WB (1997). "Prevention of heart failure by antihypertensive drug treatment in older persons with isolated systolic hypertension. SHEP Cooperative Research Group". JAMA : the Journal of the American Medical Association. 278 (3): 212–6. PMID 9218667. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  8. ↑ "Effects of treatment on morbidity in hypertension. II. Results in patients with diastolic blood pressure averaging 90 through 114 mm Hg". JAMA : the Journal of the American Medical Association. 213 (7): 1143–52. 1970. PMID 4914579. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  9. ↑ "A randomized trial of propranolol in patients with acute myocardial infarction. I. Mortality results". JAMA : the Journal of the American Medical Association. 247 (12): 1707–14. 1982. PMID 7038157. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  10. ↑ Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G (2000). "Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators". The New England Journal of Medicine. 342 (3): 145–53. doi:10.1056/NEJM200001203420301. PMID 10639539. Retrieved 2011-04-05. Unknown parameter |month= ignored (help)
  11. ↑ Fox KM (2003). "Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomised, double-blind, placebo-controlled, multicentre trial (the EUROPA study)". Lancet. 362 (9386): 782–8. Retrieved 2011-04-05. Unknown parameter |month= ignored (help)
  12. ↑ 12.0 12.1 "Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. The SOLVD Investigattors". The New England Journal of Medicine. 327 (10): 685–91. 1992. doi:10.1056/NEJM199209033271003. PMID 1463530. Retrieved 2011-04-05. Unknown parameter |month= ignored (help)
  13. ↑ Chadda K, Goldstein S, Byington R, Curb JD (1986). "Effect of propranolol after acute myocardial infarction in patients with congestive heart failure". Circulation. 73 (3): 503–10. PMID 3948357. Retrieved 2011-04-05. Unknown parameter |month= ignored (help)
  14. ↑ "The effect of digoxin on mortality and morbidity in patients with heart failure. The Digitalis Investigation Group". The New England Journal of Medicine. 336 (8): 525–33. 1997. doi:10.1056/NEJM199702203360801. PMID 9036306. Retrieved 2011-04-05. Unknown parameter |month= ignored (help)
  15. ↑ 15.0 15.1 "The effect of diltiazem on mortality and reinfarction after myocardial infarction. The Multicenter Diltiazem Postinfarction Trial Research Group". The New England Journal of Medicine. 319 (7): 385–92. 1988. doi:10.1056/NEJM198808183190701. PMID 2899840. Retrieved 2011-04-05. Unknown parameter |month= ignored (help)
  16. ↑ Grogan M, Smith HC, Gersh BJ, Wood DL (1992). "Left ventricular dysfunction due to atrial fibrillation in patients initially believed to have idiopathic dilated cardiomyopathy". The American Journal of Cardiology. 69 (19): 1570–3. PMID 1598871. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  17. ↑ Connolly HM, Oh JK, Orszulak TA, Osborn SL, Roger VL, Hodge DO, Bailey KR, Seward JB, Tajik AJ (1997). "Aortic valve replacement for aortic stenosis with severe left ventricular dysfunction. Prognostic indicators". Circulation. 95 (10): 2395–400. PMID 9170402. Retrieved 2011-04-06. Unknown parameter |month= ignored (help)
  18. ↑ Bolling SF, Pagani FD, Deeb GM, Bach DS (1998). "Intermediate-term outcome of mitral reconstruction in cardiomyopathy". The Journal of Thoracic and Cardiovascular Surgery. 115 (2): 381–6, discussion 387–8. PMID 9475533. Retrieved 2011-04-06. Unknown parameter |month= ignored (help)
  19. ↑ Scognamiglio R, Rahimtoola SH, Fasoli G, Nistri S, Dalla Volta S (1994). "Nifedipine in asymptomatic patients with severe aortic regurgitation and normal left ventricular function". The New England Journal of Medicine. 331 (11): 689–94. doi:10.1056/NEJM199409153311101. PMID 8058074. Retrieved 2011-04-06. Unknown parameter |month= ignored (help)
  20. ↑ Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Nishimura RA, Carabello BA, Faxon DP, Freed MD, Lytle BW, O'Gara PT, O'Rourke RA, Shah PM (2008). "2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Journal of the American College of Cardiology. 52 (13): e1–142. doi:10.1016/j.jacc.2008.05.007. PMID 18848134. Retrieved 2011-04-06. Unknown parameter |month= ignored (help)
  21. ↑ 21.0 21.1 Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM; et al. (2022). "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 145 (18): e876–e894. doi:10.1161/CIR.0000000000001062. PMID 35363500 Check |pmid= value (help).
  22. ↑ 22.0 22.1 22.2 Yancy CW, Jessup M, Bozkurt B, Masoudi FA, Butler J, McBride PE; et al. (2013). "2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. doi:10.1016/j.jacc.2013.05.019. PMID 23747642.
  23. ↑ 23.0 23.1 23.2 Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119 (14):1977-2016.DOI:10.1161/CIRCULATIONAHA.109.192064 PMID:19324967
  24. ↑ Pfeffer MA, Braunwald E, Moyé LA, Basta L, Brown EJ, Cuddy TE; et al. (1992). "Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. The SAVE Investigators". N Engl J Med. 327 (10): 669–77. doi:10.1056/NEJM199209033271001. PMID 1386652.
  25. ↑ Jong P, Yusuf S, Rousseau MF, Ahn SA, Bangdiwala SI (2003). "Effect of enalapril on 12-year survival and life expectancy in patients with left ventricular systolic dysfunction: a follow-up study". Lancet. 361 (9372): 1843–8. doi:10.1016/S0140-6736(03)13501-5. PMID 12788569.
  26. ↑ Køber L, Torp-Pedersen C, Carlsen JE, Bagger H, Eliasen P, Lyngborg K; et al. (1995). "A clinical trial of the angiotensin-converting-enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial infarction. Trandolapril Cardiac Evaluation (TRACE) Study Group". N Engl J Med. 333 (25): 1670–6. doi:10.1056/NEJM199512213332503. PMID 7477219.
  27. ↑ Afilalo J, Majdan AA, Eisenberg MJ (2007). "Intensive statin therapy in acute coronary syndromes and stable coronary heart disease: a comparative meta-analysis of randomised controlled trials". Heart. 93 (8): 914–21. doi:10.1136/hrt.2006.112508. PMC 1994400. PMID 17277349.
  28. ↑ Heart Protection Study Collaborative Group. Emberson JR, Ng LL, Armitage J, Bowman L, Parish S; et al. (2007). "N-terminal Pro-B-type natriuretic peptide, vascular disease risk, and cholesterol reduction among 20,536 patients in the MRC/BHF heart protection study". J Am Coll Cardiol. 49 (3): 311–9. doi:10.1016/j.jacc.2006.08.052. PMID 17239712.
  29. ↑ Preiss D, Campbell RT, Murray HM, Ford I, Packard CJ, Sattar N; et al. (2015). "The effect of statin therapy on heart failure events: a collaborative meta-analysis of unpublished data from major randomized trials". Eur Heart J. 36 (24): 1536–46. doi:10.1093/eurheartj/ehv072. PMC 4769322. PMID 25802390.
  30. ↑ Scirica BM, Morrow DA, Cannon CP, Ray KK, Sabatine MS, Jarolim P; et al. (2006). "Intensive statin therapy and the risk of hospitalization for heart failure after an acute coronary syndrome in the PROVE IT-TIMI 22 study". J Am Coll Cardiol. 47 (11): 2326–31. doi:10.1016/j.jacc.2006.03.034. PMID 16750703.
  31. ↑ Strandberg TE, Holme I, Faergeman O, Kastelein JJ, Lindahl C, Larsen ML; et al. (2009). "Comparative effect of atorvastatin (80 mg) versus simvastatin (20 to 40 mg) in preventing hospitalizations for heart failure in patients with previous myocardial infarction". Am J Cardiol. 103 (10): 1381–5. doi:10.1016/j.amjcard.2009.01.377. PMID 19427432.
  32. ↑ Pfeffer MA, McMurray JJ, Velazquez EJ, Rouleau JL, Køber L, Maggioni AP; et al. (2003). "Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both". N Engl J Med. 349 (20): 1893–906. doi:10.1056/NEJMoa032292. PMID 14610160. Review in: ACP J Club. 2004 Jul-Aug;141(1):3
  33. ↑ Dargie HJ (2001). "Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomised trial". Lancet. 357 (9266): 1385–90. doi:10.1016/s0140-6736(00)04560-8. PMID 11356434. Review in: ACP J Club. 2002 Jan-Feb;136(1):7
  34. ↑ 34.0 34.1 Exner DV, Dries DL, Waclawiw MA, Shelton B, Domanski MJ (1999). "Beta-adrenergic blocking agent use and mortality in patients with asymptomatic and symptomatic left ventricular systolic dysfunction: a post hoc analysis of the Studies of Left Ventricular Dysfunction". J Am Coll Cardiol. 33 (4): 916–23. doi:10.1016/s0735-1097(98)00675-5. PMID 10091816.
  35. ↑ Moss AJ, Zareba W, Hall WJ, Klein H, Wilber DJ, Cannom DS; et al. (2002). "Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction". N Engl J Med. 346 (12): 877–83. doi:10.1056/NEJMoa013474. PMID 11907286. Review in: ACP J Club. 2002 Nov-Dec;137(3):81
  36. ↑ Dargie HJ, Hildebrandt PR, Riegger GA, McMurray JJ, McMorn SO, Roberts JN; et al. (2007). "A randomized, placebo-controlled trial assessing the effects of rosiglitazone on echocardiographic function and cardiac status in type 2 diabetic patients with New York Heart Association Functional Class I or II Heart Failure". J Am Coll Cardiol. 49 (16): 1696–704. doi:10.1016/j.jacc.2006.10.077. PMID 17448371.
  37. ↑ Goldstein RE, Boccuzzi SJ, Cruess D, Nattel S (1991). "Diltiazem increases late-onset congestive heart failure in postinfarction patients with early reduction in ejection fraction. The Adverse Experience Committee; and the Multicenter Diltiazem Postinfarction Research Group". Circulation. 83 (1): 52–60. doi:10.1161/01.cir.83.1.52. PMID 1984898.
  38. ↑ Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW (May 2022). "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". Circulation. 145 (18): e895–e1032. doi:10.1161/CIR.0000000000001063. PMID 35363499 Check |pmid= value (help).
  39. ↑ Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202

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