MANAGEMENT
- Avoid smoking, alcohol
- Treat HTN, DM
- Treat high cholesterol
- Weight reduction, if obese
- Limit salt & fluid intake (as needed) (about 2g salt/d is good. Too much restriction can be harmful)
MEDICINES
6 GROUPS OF MEDICINES
- Diuretics in all
- ACE inhib./ARB patients
- Beta blockers
- Aldosterone antagonists in some
- Vasodilators patients
- Digoxin
- Ivabradine
1) Diuretics:
- Thiazides (for mild edema)
- Furosemide (for moderate to severe edema)
2) ACE inhib/ARBs: Very useful drugs
- Improve myocardial function
- Slow the disease progression
(ACE are first choice, much better than ARBs) Examples: Captopril & Enalapril (ACE), Valsartan, Candesartan (ARBs)
MODE OF ACTION OF ACE/ARBs:
These drugs block the RAAS system which is overactive in heart failure.
(Absolutely contraindicated in pregnancy, history of angioedema, bilateral Renal Artery stenosis)
3) Beta blockers: A “laazim” part of CHF therapy
- Use only those which have been used in trials (Metoprolol, Carvedilol, Bisoprolol)
- Start a small dose then increase slowly
- Beta blockers act by blocking the sympathetic system, which is overactive in CHF patients.
- They improve survival and also reduce chances of sudden death
BE CAREFUL! If a patient presents for the first time in acute pulmonary edema (acute CHF), do not start beta blockers at that time. Start later when he is stable.
4) Aldosterone antagonists (spironolactone)
- Also block the RAAS system
- Used in advanced cases (NYHA class 3 & 4)
- Be careful of hyperkalemia (why?) - ace + sparing = hyperkalemia
5) Vasodilators: e.g., hydralazine & nitrates
- Used if ACE & ARBs can’t be given
6) Digoxin:
- Increases myocardial contraction
- Not used too much now
- Digoxin toxicity can occur easily
- Very good drug if atrial fibrillation. is also present
7) Ivabradine:
- It helps by reducing the heart rate
- If the patient is taking beta blockers and still symptomatic, then add Ivabradine.
Other treatment methods
Cardiac transplant:
- For severe CHF not responding to meds
- A complicated procedure, not done frequently