Heart failure learning module 3: pharmacological management

Released1 November 2017     Expires: 01 November 2019      Programme:

Introduction

The aims of chronic heart failure (CHF) management are:

  1. symptomatic relief
  2. prevent hospital admission
  3. improve survival.

Elderly woman patient foreground. Nurse, daughter. Nursing home.

These can be achieved through optimal non-pharmacological and pharmacological management. Non-pharmacological interventions, such as lifestyle modification, psychosocial support and patient self-management, cannot be overlooked. Ideally a multidisciplinary team that encompasses primary, secondary and tertiary care would ensure a holistic approach to managing heart failure.

Optimal pharmacological and non-pharmacological (including device-based treatment) management have had an enormous beneficial impact on the clinical course of heart failure. This module will focus on lifestyle modifications and pharmacological treatment.

Goals of heart failure treatment(2)
Box 1. Goals of heart failure treatment2

There are national and international guidelines on the management of heart failure with reduced ejection fraction (HeFREF). The National Institute for Health and Care Excellence (NICE), European Society of Cardiology (ESC) and the Scottish Intercollegiate Guidelines Network (SIGN) have produced guidelines on the management of heart failure in primary and secondary care.1,2,3

Goals of heart failure treatment(2)
Box 2. New York Heart Association (NYHA) classification

Lifestyle

The key components of lifestyle modification for patients with heart failure are:1-3

  • exercise
  • diet and weight control
  • alcohol intake
  • smoking cessation
  • patient education and self-care behaviours.

Exercise

Guidance in older textbooks is that patients with heart failure should be advised to rest as much as possible. Most patients with heart failure have fatigue and exertional dyspnoea that make exercise unappealing. In addition, depression and anxiety are common in patients with heart failure which may reduce the motivation to exercise.

However, starting from the mid-1990s, a large body of evidence has accumulated showing that exercise training can improve exercise tolerance and potentially reverse many of the abnormalities of skeletal muscle morphology and function seen in patients. A recent meta-analysis of cardiac rehabilitation in patients with heart failure and New York Heart Association (NYHA) II-IV symptoms found a reduction in hospitalisation rates and improvements in quality of life measures regardless of the ‘dose’ or form exercise involved.4

NICE guidelines recommend that patients with stable chronic heart failure, should be offered a supervised group exercise-based rehabilitation programme.1 The ESC guidelines on heart failure recommend that patients with heart failure are reassured about the benefits of exercise and are encouraged to exercise regularly.2

Weight control

Patients with heart failure should be advised to monitor their weight regularly to detect rapid weight gain which may be a consequence of fluid retention.5 Diuretic dose may be altered accordingly:5

  • increase dose if ≥2 kg weight gain in three days – a sign of developing congestion
  • reduce dose if ≥2 kg weight loss in three days – a sign of excessive diuresis.

While obesity increases the risk of developing heart failure (5-7% for every 1 kg/m2)6, overweight or obese patients with heart failure have a lower mortality rate than normal or underweight patients.7,8 It is thus not clear whether the overweight patient with heart failure should be counselled to lose weight.

Weight loss is associated with reduced left ventricular (LV) mass, LV thickness and diastolic dimensions,9 and weight loss in obese patients with heart failure and reduced left ventricular ejection fraction (LVEF) may improve LV systolic function.10

At the other end of the scale, cachexia (>5% weight loss in 12 months)11 and unintentional weight loss is associated with an adverse prognosis in chronic heart failure.12 The cause of cachexia in heart failure is not clear but may be due, in part, to neuro-hormonal activation:13 treatment with angiotensin-converting enzyme (ACE) inhibitors is associated with a lower risk of weight loss,14 and treatment with a beta blocker may prevent weight loss and promote weight gain in patients with heart failure.15

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