KEY POINTS FOR CLINICIANS
- Control the risks for the development and progression of heart failure (HF) by controlling hypertension, diabetes, myocardial ischemia, and tobacco and alcohol use.
- Treat HF with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or beta-blockers, used alone or in combination; add spironolactone and carvedilol (or change current beta-blocker to carvedilol) in severe HF; institute aerobic exercise program.
- Control symptoms with diuretics, restricted dietary sodium intake, and digoxin.
- Provide close follow-up that is comprehensive and multidisciplinary, including intensive patient education; self-monitoring of weight, symptoms, and blood pressure; and periodic telephone or in-home follow-up between scheduled office visits.
Heart failure (HF) affects more than 2 million adults in the United States.1 This common, costly, and disabling disorder mainly affects the elderly, with prevalence rates of up to 10% in patients older than 65 years.2,3 The management of HF is responsible for millions of outpatient visits per year,4 is the most common discharge diagnosis for Medicare beneficiaries,5 and accounts for more than 5% of total health care dollars spent.6
Treatment
Major advances in the pharmacologic treatment of heart failure (HF) have emerged in recent years. An approach to the diagnosis and evaluation of HF is described elsewhere.7 This article summarizes the evidence for outpatient treatment of HF. Current intervention trials do not distinguish between systolic and diastolic heart failure; it is therefore unknown whether or how drug therapy should be tailored according to the type of HF. The treatment of cardiac dysrhythmias in the setting of HF is beyond the scope of this article and is presented elsewhere.8Table 1 compares the available outpatient treatments of HF and includes the levels of evidence, numbers needed to treat, and appropriate situations for use. In the remainder of this article, we will discuss pharmacologic and nonpharmacologic management, including identification of ineffective treatments.
TABLE 1
Treatment options in heart failure
| Strength of recommendation (level of evidence)* | Treatment | NNT (Time)† | Use in NYHA class | Comments |
|---|---|---|---|---|
| A (1a) | Angiotensin-converting9-14 enzyme (ACE) inhibitors | 24 (90 days to 2 years) | I–IV | Even moderate doses (equivalent to 10 to 20 mg enalapril per day) provide benefit |
| A (1b) | Angiotensin-receptor blockers (ARBs)15,16 | Similar to ACE inhibitors | I–IV | Useful in patients who do not tolerate ACE inhibitors; may be combined with ACE inhibitors or beta-blockers, but not both |
| A (1a) | Beta-blockers (metoprolol, bisoprolol, carvedilol)17-20 | 24 (1 to 2 years) | I–IV | Usually added to ACE inhibitors or ARBs. May also be useful if concomitant tachydysrhythmias are present and in the post-MI period |
| A (1b) | Carvedilol21 | 18 (10 months) | III–IV | Add carvedilol if not already taking beta-blocker or change current beta-blocker to carvedilol |
| A (1b) | Spironolactone23 | 9 (2 years) | III–IV | NNT = 4 (2 years) to prevent hospitalization for HF. Severe hyperkalemia important safety concern (NNH = 195 over 2 years) |
| A (1b) | Hydralazine + isosorbide dinitrate (ISDN)24,25 | 19 (6 years) | I–IV | Use limited by poor tolerability |
| B (1a) | Digoxin26-28 | N/A | I–IV | No mortality benefit. NNT = 22 to prevent 1 hospitalization over 3 years. Increased risk of hospitalization for digoxin toxicity (NNH = 94 over 3 years) |
| B (2b) | Diuretics (furosemide, bumetanide, torsemide)29-32 | N/A | I–IV | Used for fluid, sodium, and symptom control. No data on mortality benefit |
| A (1b) | Aerobic exercise38-40 | 4 (14 months) | I–IV | Decreases hospitalization for HF (NNT = 5). Even brief symptom-limited exercise in severe HF has benefit in improving quality of life |
| A (1b) | Comprehensive, multi-disciplinary outpatient visits | N/A | I–IV | No mortality benefit. NNT = 5 for 3 months to prevent repeat hospitalization. Includes some combination of intensive education, medication monitoring, individualized diet modification, telephone/home visit follow-up between scheduled outpatient visits |
| B (5) | Dietary sodium restriction8,36,37 | N/A | I–IV | Recommended as standard practice, but no morbidity or mortality data from RCTs |
| C (2a) | Antiplatelet therapy and anticoagulation in HF with sinus rhythm33,35,58 | N/A | N/A | Antiplatelet therapy not useful. No data to support routine anticoagulation, although may be useful in severe HF. Patients with concomitant atrial fibrillation should be anticoagulated if no contraindications |
| D (1b) | Calcium channel blockers (CCBs)46-50 | N/A | N/A | Short-acting CCBs worsen HF. Newer, long-acting CCBs do not worsen HF, but there is no evidence of morbidity or mortality benefit |
| D (1b) | Intermittent positive inotrope (oral or intravenous)(dobutamine, milrinone)51-53 | N/A | N/A | Increased mortality (NNH = 17 over 5 months), increased hospitalizations for worsening HF (NNH = 20), and serious adverse reactions (NNH = 25) |
| *Based on the guidelines for evidence quality outlined by the Center for Evidence-Based Medicine. Available at http://cebm.jr2.ox.ac.uk/docs/levels.html. | ||||
| †NNT = number needed to treat to prevent 1 death over specified time period unless otherwise noted. | ||||
| HF, heart failure; MI, myocardial infarction; NNH, number needed to harm; NNT, number needed to treat; NYHA, New York Heart Association classification; RCT, randomized controlled trial. | ||||
Pharmacologic treatment
Angiotensin-converting enzyme inhibitors. A systematic review9 of 32 trials with a total of 7105 patients demonstrated that mortality rates were lower in patients taking an angiotensin-converting enzyme (ACE) inhibitor than in those not taking one (number needed to treat [NNT] = 24 for > 90 days, meaning that 1 fewer death occurs for every 24 patients who take an ACE inhibitor for more than 90 days). In addition, there is a reduction in the combined endpoints of death and hospitalization because of HF (NNT = 11). Although most of this benefit was realized in the first 90 days of therapy, benefits lasted for 4 to 5 years and were more pronounced in patients categorized in more severe New York Heart Association (NYHA) HF classes10 (class I: no limitation of activities; class II: slight limitation of activity; class III: marked limitation of activity and comfortable only at rest; class IV: symptoms at rest).