Congestive Heart Failure: Guide to Management

Bruce D. Hettleman, MD

Congestive heart failure is a varied and progressive clinical syndrome resulting from an initial myocardial insult and subsequent complex pathophysiology. It is common in western populations and represents a growing public health concern. Currently, approximately 4.7 million people have symptomatic congestive heart failure in the United States with about 550,000 new cases per year. Congestive heart failure is the #1 DRG for hospitalizations with high readmission and mortality rates. A multidisciplinary approach is commonly used to treat heart failure and subspecialty care is typically required.

After an initial cardiac insult resulting from disease processes as diverse as hemachromatosis to coronary artery disease, metabolic changes ensue. Neurohormonal activation is an important response that accompanies progression of both cardiac dysfunction and symptomatic presentation. Many basic and clinical investigations have shown the importance of the renin-angiotensin-aldosterone system in the progression of heart failure. Blockade of this system through the inhibition of angiotensin-converting enzyme (ACE) limits the production of angiotensin II and have been shown to reduce mortality in heart failure. Blockade of the excessive sympathetic activity commonly seen in congestive heart failure with the use of beta blockers has been shown to offer additional significant benefit to mortality and well-being. The combination of ACE inhibitors and beta blockade interrupts the progressive disease process and slows the inevitable decline that is commonly seen with congestive heart failure.

Treatment of heart failure involves both improving the patient's well-being and stabilizing the underlying disease process. Diuretic therapy is an important part of the initial treatment of congestive heart failure. It is important to try and relieve the edema, pulmonary congestion, and normalize filling pressures if possible. Inotropic agents have been disappointing. Many agents have been tested and have not been brought to market because of excess mortality. However, several studies have shown symptomatic benefit from digoxin without excess mortality. While digoxin does have a relatively weak positive inotropic effect, it also has an important neurohormonal modulating effect. Accordingly, digoxin should be strongly considered for patients who have symptomatic congestive heart failure. Digoxin should be used in conjunction with other treatments including ACE inhibitors, diuretics, and beta blockers.

It is now clear that beta blockade is an important and routine use in the treatment of patients with left ventricular systolic dysfunction (of less than 40%) and New York Heart Association Class II to IV heart failure. Trials in over 10,000 patients have shown a consistent and remarkable improvement in both mortality and morbidity. Carvedilol has recently been found to offer benefits in Class IV heart failure patients.

As noted above, ACE inhibitors are clearly important in the treatment of heart failure. Angiotensin II receptor blockers have also been studied. However, ACE inhibitors rather than angiotensin receptor blockers continue to be the agent of choice for the blockade of the renin-angiotensin system in patients with heart failure. Angiotensin II receptor blockers have clear efficacy in ACE-intolerant patients. The addition of angiotensin II receptor blockers to ACE inhibitors and beta blockers is not currently recommended.

Administration of the aldosterone inhibitor spironolactone at low dose should be offered to patients already on standard therapy who have recurrent or severe symptoms. Serum potassium concentration should be monitored after the first week of therapy and then at regular intervals, especially if diuretic dosing or renal function may change.

New indications for the placement of AICDs and biventricular pacing will be reviewed.

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