Congestive heart failure Treatment of underlying causes

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Congestive Heart Failure Microchapters
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Pathophysiology Systolic Dysfunction Diastolic Dysfunction HFpEF HFrEF
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Differentiating Congestive heart failure from other Diseases
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Medical Therapy:
Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF Diuretics ACE Inhibitors Angiotensin receptor blockers Aldosterone Antagonists Beta Blockers Ca Channel Blockers Nitrates Hydralazine Positive Inotropics Anticoagulants Angiotensin Receptor-Neprilysin Inhibitor Antiarrhythmic Drugs Nutritional Supplements Hormonal Therapies Drugs to Avoid Drug Interactions Treatment of underlying causes Associated conditions
Exercise Training
Surgical Therapy: Biventricular Pacing or Cardiac Resynchronization Therapy (CRT) Implantation of Intracardiac Defibrillator Ultrafiltration Cardiac Surgery Left Ventricular Assist Devices (LVADs) Cardiac Transplantation
ACC/AHA Guideline Recommendations Initial and Serial Evaluation of the HF Patient Hospitalized Patient Patients With a Prior MI Sudden Cardiac Death Prevention Surgical/Percutaneous/Transcather Interventional Treatments of HF 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) Patients with current or prior symptoms of heart failure (Stage C) Patients with refractory end-stage heart failure (Stage D) Coordinating Care for Patients With Chronic HF Quality Metrics/Performance Measures
Implementation of Practice Guidelines
Congestive heart failure end-of-life considerations
Specific Groups: Special Populations Patients who have concomitant disorders Obstructive Sleep Apnea in the Patient with CHF NSTEMI with Heart Failure and Cardiogenic Shock
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Treatment of the underlying cause of heart failure including ischemic heart disease, hypertension, renovascular disease, or valvular heart disease is critical in the management of the patient with congestive heart failure.

Ischemic Heart Disease

Underlying ischemic heart disease is the most common cause of chronic congestive heart failure and is the underlying cause of heart failure in 50% to 75% of patients. Ischemic heart disease results in systolic dysfunction of the heart due to irreversible damage of the left ventricle if there has been a prior MI. There can also be viable tissue that is stunned or hibernating as a cause of heart failure. The management of these patients consists of risk factor modification (for example with the use of statins or beta blockers ) as well as the relief of angina (for example with the use of nitrates ). Revascularization (percuataneous coronary intervention or coronary artery bypass grafting) is indicated in the following scenarios:

• To improve symptoms.
• To improve prognosis. If there is a perfusion defect, revascularization may improve prognosis.
• To prevent recurrent heart failure decompensation. If the patient has repeated episodes of congestive heart failure decompensation, revascularization may be indicated.

2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure

Class IIa

1. Coronary revascularization is reasonable in patients with CAD in whom symptoms (angina) or demonstrable myocardial ischemia is judged to be having an adverse effect on symptomatic HFpEF despite GDMT. (Class IIa, Level of Evidence: C)

Hypertension

Hypertension is a common underlying cause of congestive heart failure. There are 2 goals in the treatment of the congestive heart failure patient with hypertension:

1. Reduce the preload and

2. Reduce the afterload

The following agents improve survival in the heart failure patient and are the preferred antihypertensive agents:

• Beta blockers
• Angiotensin-converting enzyme inhibitors
• Angiotensin receptor blockers in patients who cannot tolerate a angiotensin converting enzyme inhibitor
• Aldosterone antagonists

Patients with bilateral renal artery stenosis tend to have a greater risk of flash pulmonary edema than those patients with unilateral renal artery stenosis. This combination of flash pulmonary edema and bilateral renal artery stenosis is known as Pickering syndrome. Is not unreasonable for patients with recurrent flash pulmonary edema and renal artery stenosis to undergo revascularization. The data in support of this recommendation however is modest.

2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure

Class I

1. In patients at increased risk, stage A HF, the optimal blood pressure in those with hypertension should be less than 130/80 mm Hg. (Class I, Level of Evidence: B-R)

2. Patients with HFrEF and hypertension should be prescribed GDMT titrated to attain systolic blood pressure less than 130 mm Hg. (Class I, Level of Evidence: C-EO)

3. Patients with HFpEF and persistent hypertension after management of volume overload should be prescribed GDMT titrated to attain systolic blood pressure less than 130 mm Hg. (Class I, Level of Evidence: C-LD)

Class IIa

1. The use of beta-blocking agents, ACE inhibitors, and ARBs in patients with hypertension is reasonable to control blood pressure in patients with HFpEF. (Class IIa, Level of Evidence: C)

Valvular Heart Disease

In 10% to 12% of patients, valvular heart disease is the underlying cause of congestive heart failure. It should also be noted that as the heart dilates in the setting of heart failure, there is often secondary mitral regurgitation and tricuspid regurgitation in many patients with a dilated cardiomyopathy. Please consult of the chapters on either mitral regurgitation or aortic regurgitation regarding the treatment of valvular heart disease. In general, once the left ventricular systolic diameter begins to increase, mitral valve repair ( left ventricular end systolic diameter greater than 45 mm) or aortic valve replacement (left ventricular end systolic diameter greater than 55 mm) is often indicated.

Other Underlying Disorders That May Warrant Treatment

There are a variety of other systemic or cardiovascular disorders that may secondarily cause heart failure, and these primary disorders may warrant treatment as well:

• Alcohol abuse: the patient should be directed to the appropriate rehabilitation program
• Cocaine abuse: the patient should be directed to the appropriate rehabilitation program
• Hemochromatosis
• Myocarditis
• Obstructive sleep apnea: a vigorous weight loss program should be implemented
• Sarcoidosis
• Systemic lupus erythematosus
• Thyroid storm