Treatment of Heart Failure

Treatment of heart failure consists of a combination of pharmacological and lifestyle interventions.

Pharmacological treatment of heart failure.

Diuretics

Diuretics are use to control fluid retention. They are also useful in decreasing fluid in the lungs and thus reducing breathlessness. It is normal to start with a low dose and then to then to increase the dose until the fluid retention is under control.

The main side effect of taking diuretics is a loss of potssium and magnesium, this is reuced if diuretics are taken alongside ACE inhibitors (see below).

Angiotensin converting enzyme (ACE) inhibitors

ACE inhibitors have been shown to prolong life expectancy and to reduce the risk of hospitalisation. ACE inhibitors lower blood pressure by widening or dilating blood vessels thus improving blood flow and decreasing the heart's workload. In some people an ACE inhibitor may cause an irritating cough.

The NICE guidance on chronic heart failure makes the following recommendations with regard to ACE inhibitors:

• All patients with heart failure due to left ventricular systolic dysfunction should be considered for treatment with an ACE inhibitor;
• ACE inhibitor therapy should be instituted in patients with heart failure due to left ventricular systolic dysfunction before beta-blockade is introduced;
• ACE inhibitor therapy should be initiated at the appropriate dose, and titrated upwards at short intervals (eg every two weeks) until the optimal tolerated or target dose is achieved.

Beta Blockers

Beta blockers work by lowering the heart rate and reducing blood pressure. They may reduce the signs and symptoms of heart failure and improve heart function.

The NICE guidance makes the following recommendations with regard to the use of beta blockers in patients with heart failure:

• Beta-blockers licensed for use in heart failure should be initiated in patients with heart failure due to LV systolic dysfunction after diuretic and ACE inhibitor therapy (regardless of whether or not symptoms persist);
• Beta-blockade therapy for heart failure should be introduced in a ‘start low, go slow’ manner, with assessment of heart rate, blood pressure, and clinical status after each titration;
• Patients who develop heart failure due to LV systolic dysfunction and who are already on treatment with a beta-blocker for a concomitant condition (eg angina, hypertension) should continue with a beta-blocker – either their current beta-blocker or an alternative licensed for heart failure treatment.

Spironolactone

This is a potassium-sparing diretic which works particularly well if given at low doses together with a beta blocker, an ACE inhibitor and a diuretic. Taken in high doses sprionolactone can raise the potassium in the blood to dangerously high levels.

Digoxin

Digoxin increases the strength of heart muscle contractions and tends to slow the heartbeat.

NICE recommends digoxin for:

• worsening or severe heart failure due to LV systolic dysfunction despite ACE inhibitor, beta-blocker and diuretic therapy;
• patients with atrial fibrillation and any degree of heart failure.

Angiotensin II receptor antagonists

These work in a similar way to ACE inhibitors but are used by people who have severe side effects with ACE inhibitors.

Lifestyle Interventions

Exercise Training

Both aerobic (eg brisk walking) and passive exercise (eg weight training) have been shown to improve patients' symptoms, exercise performance and quality of life without any damaging effects to the heart. One study has shown that slow deep breathing exercise may reduce breatlessness and increase oxygen saturation.

Rehabilitation Programmes

Rehabilitation programmes that combine exercise, physchological support and education have been shown to be effective in reducing hospitalisation rates, improving quality of life and enhancing exercise performance.

Smoking

The NICE guidance recommends that "Patients must be strongly advised not to smoke. Referral to smoking cessation services services should be considered."

Alcohol

People who have alcohol-related heart failure may make a complete recovery or considerable improvement if they give up drinking. For others the picture is less clear cut but drinking pints of lager or beer are likely to add to fluid retention problems.

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