Recent expert guidelines for evaluating the severity of heart failure and determining treatments uses a staging system that is similar to that used for major cancers:
- Stage A: Patients are at high risk for heart failure but there is no evidence of structural damage to the heart. Risk factors include high blood pressure, heart diseases, diabetes, previous use of medications toxic to the heart (such in some chemotherapies), history of rheumatic fever, family history of cardiomyopathy.
- Stage B: Patients have a structural heart abnormality but no symptoms of heart failure. Such abnormalities include left ventricular hypertrophy or dilatation, asymptomatic valvular heart disease, a previous heart attack.
- Stage C: Patients have a structural abnormality and have present or previous symptoms of heart failure, including shortness of breath or fatigue related to the heart problem.
- Stage D: Patients have end-stage symptoms that do not respond to standard treatments.
Treatments for Conditions that Cause Heart Failure (Stage A)
The first step in managing congestive heart failure is to treat the primary conditions causing or complicating heart failure. They typically include one or more of the following:
- Coronary artery disease. Treatment includes lifestyle management (including diet, exercise, and smoking cessation), medications, and possibly bypass or angioplasty. Quitting smoking, for example, appears to reduce illness and prolong survival within two years, with benefits comparable to those of drug treatments. [For more information see Well-Connected Report #3, Angina and Coronary Artery Disease.]
- Valvular abnormalities, such as aortic stenosis and mitral regurgitation. Surgery may be required.
- High blood pressure. The goal is to aim for a systolic pressure below 140 (130 for diabetics) and a diastolic blood pressure below 80 mg. This is especially important for people with diabetes. Effective reduction of blood pressure reduces the risk of heart failure by 30% to 50%. Diuretics continue to be the best choice for most older adults. In important studies in 2002 and 2003, diuretics achieved a lower risk for heart failure-and also stroke and angina--than an ACE inhibitor. (ACE inhibitors, however, were more than effective than diuretics in one major trial and are important for patients with diabetes or kidney problems.) Of note, a major study reported that calcium channel blockers were not as effective as a diuretic in preventing heart failure. In fact, the drugs may slightly increase the risk. [For more information, see Well-Connected Report #14, High Blood Pressure.]
- Diabetes. Treating diabetes is extremely important for reducing the risk for heart disease. ACE inhibitors are especially beneficial, particularly for people with diabetes. [For information on treatments, see Well-Connected Report #60, Type 2 Diabetes or Report #9 Type 1 Diabetes.]
- Abnormal health rhythms (arrhythmias). Ventricular assisted devices, notably biventricular pacers (BVPs), are proving to be important in preventing hospitalizations for patients with these conditions.
- Anemia. Giving erythropoietin (EPO) and iron injections to heart failure patients with underlying anemia not only reverses the anemia, but may markedly improve heart symptoms as well. [For more information, see Well-Connected Report #57, Anemia.]
- Thyroid disorders.
Drug Treatment of Heart Failure in Stages B, C, and D
Treating heart failure itself at as early a stage as possible offers the best chance for a longer and better-quality life. A number of classes of medications are used to treat heart failure:
- ACE inhibitors (which open blood vessels) are used for virtually all patients in stages B through D. The combination of the diuretic spironolactone along with an ACE inhibitor may have specific advantages. This combination may more effective in non-African-American patients than in African-Americans.
- Beta blockers are increasingly recommended once fluid volume has been stabilized with other agents.
- Digoxin (Lanoxin) is an older drug that is still useful to reduce the need for hospitalization. Unlike the other treatments for CHF, it increases the hearts ability to contract. Digoxin may be added in patients with persistent symptoms or for those with atrial fibrillation.
- Vasodilators are agents that open blood vessels. A combination of them, hydralazine and nitrates, are conferring survival advantages, particularly for African-American patients.
The specific medication or, more commonly, a combination of medications, is determined by the type and severity of the heart failure.
General Guidelines for Heart Failure Surgery
Heart transplantation is the most important surgical procedure for very severe heart failure that does not respond to any other treatments. Studies indicate that most patients in stable condition can be managed safely with medications for many months while waiting for a transplant. A number of procedures or devices are also now available for patients waiting for transplants. Some may even offer permanent alternatives. They include the following:
- Portable pumps that continuously infuse medications such as dopamine and prostaglandin E-1 can allow the patient to remain mobile and active.
- Implanted devices for controlling arrhythmias and improving pumping actions.
- Surgical innovations, including ventricular remodeling, dynamic cardiomyoplasty, and the artificial heart.
Patients may also need procedures to treat conditions, such as coronary artery disease or mitral valve prolapse, that contribute to heart failure.