Congestive heart failure treatment of patients with current or prior symptoms of heart failure (Stage C)
| Heart failure | |
| ICD-10 | I50.0 |
|---|---|
| ICD-9 | 428.0 |
| DiseasesDB | 16209 |
| MedlinePlus | 000158 |
| eMedicine | med/3552 |
| MeSH | D006333 |
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General recommendations
Several measures [1] have been listed for patients in Stage A or B as previously mentioned and the Class 1 recommendations for those patients are also appropriate for patients with current or previous symptoms of HF. The effectiveness of diuretics and safety of their usage is an important aspect of the treatment that should be closely monitored along daily measurement of weight and moderate sodium restriction. Physical activity is highly recommended, although heavy labor or sports shouldn’t be a part of it, because the reduction of physical activity promotes physical deconditioning, and an increase of weigh which causes more strain on the failing heart.[2] Patients with chronic conditions such as HF are also recommended to be immunized with influenza and pneumococcal vaccines in order to reduce the risk of respiratory infection.
Drugs that should be avoided or used with caution in patients with HF
Pharmacological therapy should be closely monitored and several classes of drugs should be avoided in case of HF:
- Calcium Channel blockers: No direct role has been attributed to this kind of drugs in the management of HF, due to negative and possible deleterious effect in patients with HF due to systolic dysfunction[3]. Vasoelective Calcium Channel blockers as amlodipine and felodipine have not been linked to adverse effect in HF treatment, but there is no direct effect for these drugs in the management of HF.[4] However, amlodipine and felodipine appear to be safe for the treatment of concomitant disease in HF patients, such as angina or hypertension.
- Antiarrhythmic agents: Negative inotropic effect exerted by most antiarrhythmic drugs can precipitate HF in patients with reduced LV function. The reduction in LV function can also reduce the elimination of these drugs leading to further drug toxicity. Other antiarrhythmic drugs can induce some proarrhythmic effect, especially class 1 agents and class 3 agents Ibutilide and sotalol;[5] the same class 3 agents in addition to dofetilide can induce torsades to pointes.
Amiodarone is considered the safest of the antiarrhythmic drugs because of its less proarrhythmic effect and is generally the preferred drug for treating arrhythmias in HF patients.
- Nonsteroidal anti-inflammatory drugs (NSAID):[6] The administration of non-selective NSAIDs in HF patients is linked with an increased risk of HF exacerbation, increased renal dysfunction, and abnormal responses to ACEIs and diuretics. COX-2 selective inhibitors have not been fully investigated, but observational studies indicate that they may be linked with an increased rate of HF exacerbation and increased mortality.
Aspirin benefits and risks are not well established in patients with HF and Vascular disease (includingCAD). The potential interaction between ACEIs and beta blockers is of great importance. Although no data has proven that aspirin causes more frequent HF exacerbations and interactions with those drugs, health care providers should be aware of the possibility of such risks, but no recommendation for or against aspirin therapy in patients with heart failure can be made before further data are available.
- Oral Hypoglycemic agents:[7] two oral hypoglycemic agents, metformin and thiazolidinediones are considered to be risky in patients with HF.
Metformin - one of the most common side effects of metformin is lactic acidosis, which can be fatal in patients with HF.
Thiazolidinediones -[8] the biggest risk of using Thiazolidinediones is fluid retention which may cause severe worsening of patients with HF.
- Antidepressants: Depression is a common finding between patients suffering from HF that is usually related to high mortality rate and bad prognosis of those patients.[9] Limited data are available on the safety and the risks associated with the usage of antidepressants in patients with heart failure. Health care providers should be aware of major cardiovascular events (as HF, MI, Stroke, cardiovascular death ) that is associated with Tricyclic antidepressants (TCAs) and Selective serotonin reuptake inhibitors (SSRIs).
- Phosphodiesterase inhibitors PDE – The PDE-3 inhibitors as[10] Cilostazol and PDE-4 as [11] Anagrelide should be avoided in patients with HF, because of an increase risk of high-output heart failure and fluid retention that is associated with those drugs.[12]
PDE-5 inhibitors such as sildenafil, vardenafil, and tadalafil, are widely used in the management of erectile dysfunction in men. The use of those agents with any form of nitrate therapy is contraindicated because of severe hypotensive effect that can be life threatening.[13] In a trial where sildenafil and placebo were randomly assigned to 34 HF patients, no significant difference of symptomatic hypotension was observed, but HF patients with borderline low blood pressure and/or low volume status are in risk of severe hypotension and should avoid any PDE-5 inhibitors use.
- Chemotherapy – Cardiotoxic chemotherapeutic agents as Cyclophosphamide, Trastuzumab, Bevacizumab and Anthracyclines, should be avoided in HF patients [14]
- Tumor Necrosis Factor alpha inhibitors TNF-alpha: New onset or worsening of pre-existing heart failure have been linked to TNF-alpha inhibitors.[15] Infliximab has been specifically contraindicated in doses over 5mg/kg in patients with heart failure.
- Antihistamines:[16] some second generation antihistamines as terfenadine and astemizole have been reported to cause long QT syndrome and would better not be used in HF patients.
Overview of Treatment of Patients With Current or Prior Symptoms of Heart Failure (Stage C)
ACC / AHA Guidelines- Patients with Reduced LVEF (DO NOT EDIT) [17]
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Class I1. Measures listed as Class I recommendations for patients in stages A and B are also appropriate for patients in Stage C. (Levels of Evidence: A, B, and C as appropriate) 2. Diuretics and salt restriction are indicated in patients with current or prior symptoms of HF and reduced LVEF who have evidence of fluid retention. (Level of Evidence: C) 3. Angiotensin converting enzyme inhibitors are recommended for all patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated. (Level of Evidence: A) 4. Beta-blockers (using 1 of the 3 proven to reduce mortality, i.e., bisoprolol, carvedilol, and sustained release metoprolol succinate) are recommended for all stable patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated. (Level of Evidence: A) 5. Angiotensin II receptor blockers approved for the treatment of HF are recommended in patients with current or prior symptoms of HF and reduced LVEF who are ACEI-intolerant (as in patients with angioedema). (Level of Evidence: A) 6. Drugs known to adversely affect the clinical status of patients with current or prior symptoms of HF and reduced LVEF should be avoided or withdrawn whenever possible (e.g., non steroidal anti-inflammatory drugs, most antiarrhythmic drugs, and most calcium channel blocking drugs; see text). (Level of Evidence: B) 7. Exercise training is beneficial as an adjunctive approach to improve clinical status in ambulatory patients with current or prior symptoms of HF and reduced LVEF. (Level of Evidence: B) 8. An implantable cardioverter-defibrillator is recommended as secondary prevention to prolong survival in patients with current or prior symptoms of HF and reduced LVEF who have a history of cardiac arrest, ventricular fibrillation, or hemodynamically destabilizing ventricular tachycardia. (Level of Evidence: A) 9. Implantable cardioverter-defibrillator therapy is recommended for primary prevention to reduce total mortality by a reduction in sudden cardiac death in patients with ischemic heart disease who are at least 40 days post-MI, have an LVEF less than or equal to 30%, with NYHA functional class II or III symptoms while undergoing chronic optimal medical therapy, and have reasonable expectation of survival with a good functional status for more than 1 year. (Level of Evidence: A) 10. Implantable cardioverter-defibrillator therapy is recommended for primary prevention to reduce total mortality by a reduction in sudden cardiac death in patients with non ischemic cardiomyopathy who have an LVEF less than or equal to 30%, with NYHA functional class II or III symptoms while undergoing chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year. (Level of Evidence: B) 11. Patients with LVEF less than or equal to 35%, sinus rhythm, and NYHA functional class III or ambulatory class IV symptoms despite recommended, optimal medical therapy and who have cardiac dyssynchrony, which is currently defined as a QRS duration greater than 0.12 ms, should receive cardiac resynchronization therapy unless contraindicated. (Level of Evidence: A) 12. Addition of an aldosterone antagonist is reasonable in selected patients with moderately severe to severe symptoms of HF and reduced LVEF who can be carefully monitored for preserved renal function and normal potassium concentration. Creatinine should be less than or equal to 2.5 mg/dL in men or less than or equal to 2.0 mg/dL in women and potassium should be less than 5.0 mEq/L. Under circumstances where monitoring for hyperkalemia or renal dysfunction is not anticipated to be feasible, the risks may outweigh the benefits of aldosterone antagonists. (Level of Evidence: B) Class IIa1. Angiotensin II receptor blockers are reasonable to use as alternatives to ACEIs as first-line therapy for patients with mild to moderate HF and reduced LVEF, especially for patients already taking ARBs for other indications. (Level of Evidence: A) 2. Digitalis can be beneficial in patients with current or prior symptoms of HF and reduced LVEF to decrease hospitalizations for HF. (Level of Evidence: B) 3. The addition of a combination of hydralazine and a nitrate is reasonable for patients with reduced LVEF who are already taking an ACEI and beta-blocker for symptomatic HF and who have persistent symptoms. (Level of Evidence: A) 4. Placement of an implantable cardioverter-defibrillator is reasonable in patients with LVEF of 30% to 35% of any origin with NYHA functional class II or III symptoms who are taking chronic optimal medical therapy and who have reasonable expectation of survival with good functional status of more than 1 year. (Level of Evidence: B) Class IIb1. A combination of hydralazine and a nitrate might be reasonable in patients with current or prior symptoms of HF and reduced LVEF who cannot be given an ACEI or ARB because of drug intolerance, hypotension, or renal insufficiency. (Level of Evidence: C) 2. The addition of an ARB may be considered in persistently symptomatic patients with reduced LVEF who are already being treated with conventional therapy. (Level of Evidence: B) Class III1. Routine combined use of an ACEI, ARB, and aldosterone antagonist is not recommended for patients with current or prior symptoms of HF and reduced LVEF. (Level of Evidence: C) 2. Calcium channel blocking drugs are not indicated as routine treatment for HF in patients with current or prior symptoms of HF and reduced LVEF. (Level of Evidence: A) 3. Long-term use of an infusion of a positive inotropic drug may be harmful and is not recommended for patients with current or prior symptoms of HF and reduced LVEF, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment (Stage D). (Level of Evidence: C) 4. Use of nutritional supplements as treatment for HF is not indicated in patients with current or prior symptoms of HF and reduced LVEF. (Level of Evidence: C) 5. Hormonal therapies other than to replete deficiencies are not recommended and may be harmful to patients with current or prior symptoms of HF and reduced LVEF. (Level of Evidence: C) |
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ACC / AHA Guidelines- Patients with HF and Normal LVEF (DO NOT EDIT) [17]
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Class I1. Physicians should control systolic and diastolichypertension in patients with HF and normal LVEF, in accordance with published guidelines. (Level of Evidence: A) 2. Physicians should control ventricular rate in patients with HF and normal LVEF and atrial fibrillation. (Level of Evidence: C) 3. Physicians should use diuretics to control pulmonary congestion and peripheral edema in patients with HF and normal LVEF. (Level of Evidence: C) Class IIa1. Coronary revascularization is reasonable in patients with HF and normal LVEF and coronary artery disease in whom symptomatic or demonstrable myocardial ischemia is judged to be having an adverse effect on cardiac function. (Level of Evidence: C) Class IIb1. Restoration and maintenance of sinus rhythm in patients with atrial fibrillation and HF and normal LVEF might be useful to improve symptoms. (Level of Evidence: C) 2. The use of beta-adrenergic blocking agents, ACEIs, ARBs, or calcium antagonists in patients with HF and normal LVEF and controlled hypertension might be effective to minimize symptoms of HF. (Level of Evidence: C) 3. The usefulness of digitalis to minimize symptoms of HF in patients with HF and normal LVEF is not well established. (Level of Evidence: C) |
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See Also
Sources
- The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult [17]
References
- ↑ 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 (2009). "2009 focused update incorporated into the ACC/AHA 2005 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): e391–479. doi:10.1161/CIRCULATIONAHA.109.192065. PMID 19324966. Retrieved 2011-04-07. Unknown parameter
|month=ignored (help) - ↑ McKelvie RS, Teo KK, McCartney N, Humen D, Montague T, Yusuf S (1995). "Effects of exercise training in patients with congestive heart failure: a critical review". Journal of the American College of Cardiology. 25 (3): 789–96. doi:10.1016/0735-1097(94)00428-S. PMID 7860930. Retrieved 2011-04-07. Unknown parameter
|month=ignored (help) - ↑ Packer M, Kessler PD, Lee WH (1987). "Calcium-channel blockade in the management of severe chronic congestive heart failure: a bridge too far". Circulation. 75 (6 Pt 2): V56–64. PMID 3552317. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Reed SD, Friedman JY, Velazquez EJ, Gnanasakthy A, Califf RM, Schulman KA (2004). "Multinational economic evaluation of valsartan in patients with chronic heart failure: results from the Valsartan Heart Failure Trial (Val-HeFT)". American Heart Journal. 148 (1): 122–8. doi:10.1016/j.ahj.2003.12.040. PMID 15215801. Retrieved 2011-04-07. Unknown parameter
|month=ignored (help) - ↑ Torp-Pedersen C, Møller M, Bloch-Thomsen PE, Køber L, Sandøe E, Egstrup K, Agner E, Carlsen J, Videbaek J, Marchant B, Camm AJ (1999). "Dofetilide in patients with congestive heart failure and left ventricular dysfunction. Danish Investigations of Arrhythmia and Mortality on Dofetilide Study Group". The New England Journal of Medicine. 341 (12): 857–65. doi:10.1056/NEJM199909163411201. PMID 10486417. Retrieved 2011-04-07. Unknown parameter
|month=ignored (help) - ↑ Heerdink ER, Leufkens HG, Herings RM, Ottervanger JP, Stricker BH, Bakker A (1998). "NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics". Archives of Internal Medicine. 158 (10): 1108–12. PMID 9605782. Retrieved 2011-04-08. Unknown parameter
|month=ignored (help) - ↑ Gan SC, Barr J, Arieff AI, Pearl RG (1992). "Biguanide-associated lactic acidosis. Case report and review of the literature". Archives of Internal Medicine. 152 (11): 2333–6. PMID 1444694. Retrieved 2011-04-08. Unknown parameter
|month=ignored (help) - ↑ Masoudi FA, Inzucchi SE, Wang Y, Havranek EP, Foody JM, Krumholz HM (2005). "Thiazolidinediones, metformin, and outcomes in older patients with diabetes and heart failure: an observational study". Circulation. 111 (5): 583–90. doi:10.1161/01.CIR.0000154542.13412.B1. PMID 15699279. Retrieved 2011-04-08. Unknown parameter
|month=ignored (help) - ↑ Swenson JR, Doucette S, Fergusson D (2006). "Adverse cardiovascular events in antidepressant trials involving high-risk patients: a systematic review of randomized trials". Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie. 51 (14): 923–9. PMID 17249635. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B (2006). "ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation". Circulation. 113 (11): e463–654. doi:10.1161/CIRCULATIONAHA.106.174526. PMID 16549646. Retrieved 2011-04-08. Unknown parameter
|month=ignored (help) - ↑ Storen EC, Tefferi A (2001). "Long-term use of anagrelide in young patients with essential thrombocythemia". Blood. 97 (4): 863–6. PMID 11159509. Retrieved 2011-04-08. Unknown parameter
|month=ignored (help) - ↑ "Anagrelide, a therapy for thrombocythemic states: experience in 577 patients. Anagrelide Study Group". The American Journal of Medicine. 92 (1): 69–76. 1992. PMID 1731512. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Lewis GD, Shah R, Shahzad K, Camuso JM, Pappagianopoulos PP, Hung J, Tawakol A, Gerszten RE, Systrom DM, Bloch KD, Semigran MJ (2007). "Sildenafil improves exercise capacity and quality of life in patients with systolic heart failure and secondary pulmonary hypertension". Circulation. 116 (14): 1555–62. doi:10.1161/CIRCULATIONAHA.107.716373. PMID 17785618. Retrieved 2011-04-08. Unknown parameter
|month=ignored (help) - ↑ Slamon DJ, Leyland-Jones B, Shak S, Fuchs H, Paton V, Bajamonde A, Fleming T, Eiermann W, Wolter J, Pegram M, Baselga J, Norton L (2001). "Use of chemotherapy plus a monoclonal antibody against HER2 for metastatic breast cancer that overexpresses HER2". The New England Journal of Medicine. 344 (11): 783–92. doi:10.1056/NEJM200103153441101. PMID 11248153. Retrieved 2011-04-08. Unknown parameter
|month=ignored (help) - ↑ Chung ES, Packer M, Lo KH, Fasanmade AA, Willerson JT (2003). "Randomized, double-blind, placebo-controlled, pilot trial of infliximab, a chimeric monoclonal antibody to tumor necrosis factor-alpha, in patients with moderate-to-severe heart failure: results of the anti-TNF Therapy Against Congestive Heart Failure (ATTACH) trial". Circulation. 107 (25): 3133–40. doi:10.1161/01.CIR.0000077913.60364.D2. PMID 12796126. Retrieved 2011-04-08. Unknown parameter
|month=ignored (help) - ↑ Yap YG, Camm AJ (2003). "Drug induced QT prolongation and torsades de pointes". Heart (British Cardiac Society). 89 (11): 1363–72. PMC 1767957. PMID 14594906. Retrieved 2011-04-08. Unknown parameter
|month=ignored (help) - ↑ 17.0 17.1 17.2 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