Congestive heart failure treatment of underlying causes
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Resident Survival Guide |
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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[1]. 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 |
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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[2]. This combination of flash pulmonary edema and bilateral renal artery stenosis is known as Pickering syndrome[3]. 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 |
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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) |
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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: B-R) |
| Class IIa |
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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[4]. 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
References
- ↑ Bortman G, Sellanes M, Odell DS, Ring WS, Olivari MT (1994). "Discrepancy between pre- and post-transplant diagnosis of end-stage dilated cardiomyopathy". The American Journal of Cardiology. 74 (9): 921–4. PMID 7977122. Retrieved 2013-04-25. Unknown parameter
|month=ignored (help) - ↑ Pickering TG, Herman L, Devereux RB, Sotelo JE, James GD, Sos TA, Silane MF, Laragh JH (1988). "Recurrent pulmonary oedema in hypertension due to bilateral renal artery stenosis: treatment by angioplasty or surgical revascularisation". Lancet. 2 (8610): 551–2. PMID 2900930. Unknown parameter
|month=ignored (help); Check date values in:|accessdate=(help);|access-date=requires|url=(help) - ↑ Messerli FH, Bangalore S, Makani H, Rimoldi SF, Allemann Y, White CJ, Textor S, Sleight P (2011). "Flash pulmonary oedema and bilateral renal artery stenosis: the Pickering syndrome". European Heart Journal. 32 (18): 2231–5. doi:10.1093/eurheartj/ehr056. PMID 21406441. Retrieved 2013-04-25. Unknown parameter
|month=ignored (help) - ↑ Jessup M, Brozena S (2003). "Heart failure". The New England Journal of Medicine. 348 (20): 2007–18. doi:10.1056/NEJMra021498. PMID 12748317. Retrieved 2013-04-25. Unknown parameter
|month=ignored (help)