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Heart failure: Difference between revisions
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The objectives of treatment in heart failure are to reduce the number of hospitalisations, increase survival and quality of life, and slow the progression of the disease while reducing the symptoms. For HFrEF, we know of many medications which achieve all these objectives. | The objectives of treatment in heart failure are to reduce the number of hospitalisations, increase survival and quality of life, and slow the progression of the disease while reducing the symptoms. For HFrEF, we know of many medications which achieve all these objectives. | ||
For HFrEF, the four most important drugs are beta blockers, ACE inhibitors or ARNIs, MRAs, and SGLT2 inhibitors. The higher the dose, the greater the benefit. These drugs are initiated in a low dose which is then | For HFrEF, the four most important drugs are beta blockers, ACE inhibitors or ARNIs, MRAs, and SGLT2 inhibitors. The higher the dose, the greater the benefit. These drugs are initiated in a low dose which is then increased until the maximum tolerated dose by the patient is reached. Usually, side effects like bradycardia, hypotension, and/or hyperkalaemia prevent further increase. Previously, one would gradually titrate the doses up over many months, but nowadays it's recommended to titrate up over 4-6 weeks. The patient taking all four of these drugs in the maximum tolerated dose is called ''optimal medical therapy'' (OMT). Unfortunately, many heart failure patients are using suboptimal doses of medications. | ||
=== Non-pharmacological treatment === | === Non-pharmacological treatment === | ||
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=== Beta blockers === | === Beta blockers === | ||
[[Beta blocker|Beta blockers]] block the sympathetic nervous system overactivation which occurs in HF and is indicated in all patients with HF (class I recommendation). | [[Beta blocker|Beta blockers]] block the sympathetic nervous system overactivation which occurs in HF and is indicated in all patients with HF (class I recommendation). Extended-release (ER) metoprolol (metoprolol depot, Selo-Zok®), carvedilol, and bisoprolol are most frequently used. The target dose of ER metoprolol is 200 mg once daily. | ||
However, beta blockers cause a temporary decrease in myocardial contractility, before the contractiliy later increases. For this reason, it's recommended to titrate up the dose of other medications before beta blockers. | |||
=== ACE inhibitors === | === ACE inhibitors === | ||
[[ACE inhibitor|ACE inhibitors]] block the RAAS overactivation which occurs in HF and is indicated in all patients with HF (class I recommendation). If ACE inhibitors are not tolerated due to [[angioedema]] or dry cough, [[Angiotensin receptor blocker|ARBs]] should be used as an alternative. | [[ACE inhibitor|ACE inhibitors]] block the RAAS overactivation which occurs in HF and is indicated in all patients with HF (class I recommendation). If ACE inhibitors are not tolerated due to [[angioedema]] or dry cough, [[Angiotensin receptor blocker|ARBs]] should be used as an alternative. | ||
Ramipril is most frequently used. | Ramipril is most frequently used. The target dose is 5 mg twice daily. | ||
=== Mineralocorticoid receptor antagonists === | === Mineralocorticoid receptor antagonists === | ||
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=== Cardiac resynchronisation therapy === | === Cardiac resynchronisation therapy === | ||
<abbr>[[Cardiac resynchronisation therapy|CRT]]</abbr> is indicated for patients with HF and [[left bundle branch block]]. Having a LBBB and heart failure worsens the heart failure because of the desynchronised contraction of the right and the left ventricle. | <abbr>[[Cardiac resynchronisation therapy|CRT]]</abbr> is indicated for patients with HF and [[left bundle branch block]]. Having a LBBB and heart failure worsens the heart failure because of the desynchronised contraction of the right and the left ventricle. CRT may be considered for other conduction blocks as well. | ||
=== Implantable cardioverter-defibrillator === | === Implantable cardioverter-defibrillator === | ||
Primary prevention of sudden cardiac death with an <abbr>[[Implantable cardioverter defibrillator|ICD]]</abbr> is indicated in all HF with an underlying ischaemic etiology and EF < 35% despite optimal medical therapy. This is a class I recommendation, as it’s effective in reducing <abbr>SCD</abbr>. In those with a non-ischaemic etiology, ICD implantation is a class IIa recommendation. | Primary prevention of sudden cardiac death with an <abbr>[[Implantable cardioverter defibrillator|ICD]]</abbr> is indicated in all HF with an underlying ischaemic etiology and EF < 35% despite optimal medical therapy. This is a class I recommendation, as it’s effective in reducing <abbr>SCD</abbr>. In those with a non-ischaemic etiology, ICD implantation is a class IIa recommendation. | ||
However, in reality, this is evaluated on a case-by-case basis, as ICDs are expensive and not risk-free to implant. | However, in reality, this is evaluated on a case-by-case basis, as ICDs are expensive and not risk-free to implant. The patient's estimated life expentancy must also be taken into account, as ICDs are rarely used for those with estimated short life expectancy (< 1 year). | ||
=== Digoxin === | === Digoxin === | ||
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* Exercise training | * Exercise training | ||
In fact, exercise training is the only intervention known to consistently improve quality of life in HFpEF. Recently, [[SGLT2 inhibitor|SGLT2 inhibitors]] were also shown to improve prognosis. | In fact, exercise training is the only intervention known to consistently improve quality of life in HFpEF. Recently, [[SGLT2 inhibitor|SGLT2 inhibitors]] were also shown to improve prognosis, and have become a class I recommendation for use in HFpEF. | ||
Notably, ACE inhibitors, ARBs, ARNIs, and beta blockers have shown to have very little to not benefit in HFpEF | Notably, ACE inhibitors, ARBs, ARNIs, and beta blockers have shown to have very little to not benefit in HFpEF. Ongoing trials will reveal whether other drugs are useful for HFpEF. | ||
[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:Internal Medicine (POTE course)]] | [[Category:Internal Medicine (POTE course)]] | ||