Treatment of Chronic Heart Failure Failure

MNEMONICS, Pharmacy and Therapeutics

Treatment of Chronic Heart Failure with reduced ejection fraction (HFrEF).

In addition to diet and exercise,  LMNOP ( for acute decompensated HF), the following mnemonic gives you treatment for chronic CHF.

ABCDEFGH of chronic HFrEF

A-ACE / ARB,* Aldosterone antagonist (spironolactone for moderate to severe congestive heart failure)*
B- Beta blockers*
C-Cardiac Rehab; Cigarette cessation†; Cut out alcohol. Consider CRT; Catheter ablation of AF, and ICD when appropriate.
D-Diuretics,† digoxin†
E-Education including a low-salt diet Diet†, Exercise†, and improvement of FAILURES.
F-Fluid and salt restriction.
G-diGoxin
H-Hydralazine + Nitrates (Isosorbide mononitrate) – consider if the patient cannot tolerate ACEI/ARB or in blacks with class III/IV

*Medications shown to improve mortality (survival) = ACE/ARB, Spironolactone, and Beta-blockers (Bisoprolol, Carvedilol, Metoprolol), and in African Americans, direct acting Vasodilators.
†Diuretics and Digoxin have been shown to improve symptoms and function.
Meds to avoid in CHF patients: NSAIDs, non-dihydropyridine CCBs (verapamil and diltiazem), TZDs.
Aldosterone receptor antagonists are indicated in patients who have a left ventricular ejection fraction < 35%.

CRT = Cardiac Resynchronization Therapy

Treatment of Chronic HF with preserved EF

  • Unlike HFrEF, there is limited direct evidence to support a specific drug regimen to treat HFpEF.
  • Diuretics for volume overload
  • Tx their hypertension (BP control), lung disease, CAD, obesity, anemia, DM, kidney disease, and sleep-disordered breathing.
  • Prevent tachycardia and ischemia
  • Tx w/ Spironolactone (Mineralocorticoid antagonists) if the patient can be carefully monitored for changes in serum potassium and renal function. Spironolactone improves LV function, but not symptoms.
  • No benefit to ACEI/ARB, PDE5 inhibitors. However, cardiologist Dr. Kazmouz recommends still using ACE/ARB in these patients for HTN management, which makes sense.
  • If a pt w/ HFpEF has AF, the preference is first to cardiovert and restore and maintain sinus rhythm. If that’s not possible, then simply rate control the patient.
  • Exercise training is the only intervention shown to improve exercise capacity and quality of life in HFpEF. If a patient is able, refer him/her to a cardiac rehabilitation program including dynamic exercise training.

“The treatment of HFpEF is largely governed by the management of associated conditions and symptoms since trial data are limited. The general principles for treatment of HFpEF are control of pulmonary congestion and peripheral edema with diuretics, treatment of systolic hypertension, prevention of rapid heart rates, particularly in patients with atrial fibrillation, and coronary revascularization in patients with coronary heart disease with ischemia judged to contribute to symptoms of HF.” UTD

 

Reference

https://www.uptodate.com/contents/treatment-and-prognosis-of-heart-failure-with-preserved-ejection-fraction

http://www.aafp.org/afp/2001/0915/p934.html

Circulation 2013;128(16):1810-1852

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