Congestive heart failure treatment of patients at high risk for developing heart failure (Stage A)

Heart failure
ICD-10	I50.0
ICD-9	428.0
DiseasesDB	16209
MedlinePlus	000158
eMedicine	med/3552
MeSH	D006333

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Overview of Treatment of Patients at High Risk for Developing Heart Failure (Stage A)

Control of Risk

Early detection and mitigation of risk factors associated with the subsequent development of heart failure may have a tremendous impact on public and individual health.

Treatment of hypertension

Controlling both systolic and diastolic hypertension has been associated with a significant reduction in the risk of subsequent HF. Control of systolic blood pressure is consistently associated with a 50% reduction in new heart failure. Other complications of hypertension include left ventricular hypertrophy (LVH), MI, stroke and sudden death.In the Framingham heart study, hypertension was present in 39% of men and in 59% of women with heart failure. These numbers emphasize the importance of managing hypertension at an early stage to avoid complications such as heart failure. Lowering both systolic and diastolic blood pressure in accordance with the recommendations provided in published guidelines has proven its effectiveness in lowering systemic vascular resistance, improving ventricular remodeling and decreasing hemodynamic load on the failing ventricle in patients with established heart failure. The treatment of hypertension in patients with HF should take into consideration the type of heart failure that is present: In systolic dysfunction the biggest problem is the impaired contractility whereas in diastolic dysfunction, the main issue is the limitation of diastolic filling and therefore abnormal forward output due to increased ventricular stiffness. When any anti-hypertensive regimen is prescribed, an important aspect to keep in mind is the presence of concomitant medical problems as CAD, Diabetes, renal disease, pulmonary disease in many patients suffering from HF, which requires the health care providers to keep in mind the priority of lowering blood pressure while trying not to affect the treatment of those diseases. Diuretic-based antihypertensive therapy has repeatedly been shown to prevent HF in a wide range of target populations.Patients may also benefit from the usage of ACE inhibitors(ACEIs) and beta blockers, which are proven to be effective in preventing HF in hypertensive individuals. However, ACEIs and beta blockers, as single therapies, are not superior to other antihypertensive drug classes in the reduction of all cardiovascular outcomes. Nevertheless, among patients with diabetes and other cardiovascular complications, ACEIs have shown to reduce the onset of HF and new-onset diabetes.Another significant reduction of HF incidence in comparison to Placebo in patients with type 2 diabetes mellitus and nephropathy has been achieved by the usage of ARB’s losartan and irbesartan. As previously mentioned an ultimate and appropriate hypertensive treatment would take under consideration all the concomitant diseases in an HF patient, and would involve multiple drugs used in combination.

Treatment of diabetes

Diabetes increases the risk of HF in all patients groups whether coronary heart disease or hypertension is present and it may cause cardiomyopathy. A gender difference in terms of HF risk in diabetic patients is present, since the increase of HF for diabetic men’s is 3 times less than diabetic women’s. In a study of patients with type 2 diabetes mellitus over 50 years old, with urinary albumin greater than 20 mg/l, 4% of patients developed HF over the study period, of whom 36 % died. Health care providers should closely monitor hyperglycemia and target a certain blood glucose level to avoid end-organ complications in such patients since each 1% increase in (Hb)A1c is associated with an 8% increase risk of heart failure, and an (Hb)A1c>10 increases the risk of HF by 1.56 compared to an (Hb)A1c less than 7 ACEIs and ARBs have been proven to reduce the development of end-organ disease and the occurrence of clinical events in diabetic patients even when hypertension is not present. Long term treatment with ACEIs and ARBs has been shown to lower various dangerous complications in diabetic patients such as renal disease and prolonged treatment with ACEI ramipril has been shown to decrease the event of cardiovascular death, MI, and HF. ARBs long term therapy has also been proven to lower cardiovascular complication, decreasing the incidence of first HF hospitalization and improving renal function in diabetic patients.

ACC / AHA Guidelines- Treatment of Patients at High Risk for Developing Heart Failure (Stage A) (DO NOT EDIT)

“

Class I 1. In patients at high risk for developing HF, systolic and diastolic hypertension should be controlled in accordance with contemporary guidelines. (Level of Evidence: A) 2. In patients at high risk for developing HF, lipid disorders should be treated in accordance with contemporary guidelines. (Level of Evidence: A) 3. For patients with diabetes mellitus (who are all at high risk for developing HF), blood sugar should be controlled in accordance with contemporary guidelines. (Level of Evidence: C) 4. Patients at high risk for developing HF should be counseled to avoid behaviors that may increase the risk of HF (e.g., smoking, excessive alcohol consumption, and illicit drug use). (Level of Evidence: C) 5. Ventricular rate should be controlled or sinus rhythm restored in patients with supraventricular tachyarrhythmias who are at high risk for developing HF. (Level of Evidence: B) 6. Thyroid disorders should be treated in accordance with contemporary guidelines in patients at high risk for developing HF. (Level of Evidence: C) 7. Healthcare providers should perform periodic evaluation for signs and symptoms of HF in patients at high risk for developing HF. (Level of Evidence: C) 8. In patients at high risk for developing HF who have known atherosclerotic vascular disease, healthcare providers should follow current guidelines for secondary prevention. (Level of Evidence: C) 9. Healthcare providers should perform a noninvasive evaluation of LV function (i.e., LVEF) in patients with a strong family history of cardiomyopathy or in those receiving cardiotoxic interventions. (Level of Evidence: C) Class IIa 1. Angiotensin converting enzyme inhibitors can be useful to prevent HF in patients at high risk for developing HF who have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors. (Level of Evidence: A) 2. Angiotensin II receptor blockers can be useful to prevent HF in patients at high risk for developing HF who have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors. (Level of Evidence: C) Class III 1. Routine use of nutritional supplements solely to prevent the development of structural heart disease should not be recommended for patients at high risk for developing HF. (Level of Evidence: C)

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See Also

• The CHF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Sources

• The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

References

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