You can do more to slow the progression of heart failure

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Applied Evidence

You can do more to slow the progression of heart failure

J Fam Pract. 2009 March;58(3):122-128

By

Adam Pleister, MD

Randy Wexler, MD, MPH, FAAFP

Terry Elton, PhD, FAHA

Don’t hesitate to urge patients to exercise—or to treat their hypertension with a streamlined 4-step approach.

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References

1. Rosamond W, Flegal K, Friday G, et al. American Heart Association: heart disease and stroke statistics–2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;115:e69-e171.

2. Lloyd-Jones DM, Larson MG, Leip EP, et al. Framingham heart study. Lifetime risk for developing congestive heart failure. Circulation. 2002;106:3068-3072.

3. Burt CW, Schappert SM. Ambulatory care visits to physicians offices, hospital outpatient departments, and emergency departments: United states, 1999-2000. Vital Health Stat 13. 2004;157:1-70

4. Levit K, Stranges E, Ryan K, et al. HCUP facts and figures, 2006: Statistics on Hospital-based Care in the United States. Rockville, MD: Agency for Healthcare Research and Quality, 2008. Available at: http://www.hcup-us.ahrq.gov/reports.jsp. Accessed February 9, 2009.

5. Criteria Committee of the New York Heart Association. Diseases of the Heart and Blood Vessels–Nomenclature and Criteria for Diagnosis. 6th ed. Boston: Little, Brown and Company; 1964.

6. Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult. Circulation. 2005;112:e154-e235.

7. Doust J, Lehman R, Glasziou P. The role of BNP testing in heart failure. Am Fam Physician. 2006;74:1893-1898.

8. Maisel A, Krishnaswamy P, Nowak R, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med. 2002;347:161-167.

9. Maisel AS. B-type natriuretic peptide (BNP) levels: diagnostic and therapeutic potential. Rev Cardiovasc Med. 2001;2(suppl 2):S13-S18.

10. Dao Q, Krishnaswamy P, Kazanegra R, et al. Utility of B-type natriuretic peptide (BNP) in the diagnosis of congestive heart failure in an urgent-care setting. J Am Coll Cardiol. 2001;37:379-385.

11. Philbin EF, Rocco TA, Jr, Lindenmuth NW, et al. Systolic versus diastolic heart failure in a community practice: clinical features, outcomes, and the use of angiotensin-converting enzyme inhibitors. Am J Med. 2000;109:605-613.

12. Piepoli MF, Flather M, Coats AJ. Overview of studies of exercise training in chronic heart failure: the need for a prospective randomized multicentre European trial. Eur Heart J. 1998;19:830-841.

13. Coats AJ, Adamopoulos S, Meyer TE, et al. Effects of physical training in chronic heart failure. Lancet. 1990;335:63-66.

14. Feldman RD, Zou G, Feagen BG, et al. The STITCH Investigators. The Simplified Treatment Intervention to Control Hypertension (STITCH) trial: A cluster randomized controlled trial of a step-care algorithm using initial fixed dose combination therapy for the management of hypertension. Presented at Scientific Sessions 2007 of the American Heart Association, November 4-7, 2007; Orlando, Fla.

15. Chobanian A, Bakris G, Black H, et al. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Hypertension. 2003;42:1206-1252.

16. Brookes L. Hypertension highlights: new drug algorithms, new drug approvals, new drugs. Available at: http://canadiancpd.medscape.com/viewarticle/568786_print. Accessed January 27, 2009.

17. Yusuf S, Sleight P, Pogue J, et al. The Heart Outcomes Prevention Evaluation Study Investigators: effects of angiotensin converting enzyme inhibitor, ramipril, on cardiovascular events in high risk patients. N Engl J Med. 2000;342:145-153.

18. Vantrimpont P, Rouleau JL, Wun CC, et al. For the SAVE Investigators. Additive beneficial effects of beta-blockers to angiotensin converting enzyme inhibitors in the Survival and Ventricular Enlargement (SAVE) study. J Am Coll Cardiol. 1997;29:229-236.

19. Juurlink DN, Mamdani M, Kopp A, et al. Drug-drug interactions among elderly patients hospitalized for drug toxicity. JAMA. 2003;289:1652-1658.

20. Rahimtoola SH. Digitalis therapy for patients in clinical heart failure. Circulation. 2004;109:2942-2946.

21. Cayley W. Digitalis for the treatment of congestive heart failure in patients in sinus rhythm. Am Fam Physician. 2004;69:71-73.

22. The ONTARGET Investigators. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med. 2008;358:1547-1559.

23. Cohn JN, Tognoni G. Valsartan Heart Failure Trial Investigators. A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure. N Engl J Med. 2001;345:1667-1675.

24. Phillips CO, Kashani A, Ko DK, et al. Adverse effects of combination angiotensin II receptor blockers plus angiotensin-converting enzyme inhibitors for left ventricular dysfunction. Arch Intern Med. 2007;167:1930-1936.

25. Mayo Clinic. Heart failure: treatments and drugs. January 3, 2008. Available at: http://www.mayoclinic.com/health/heart-failure.DS00061/DSECTION=treatments-and-drugs. Accessed January 30, 2009.

26. Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. 2005;352:225-237.

27. Blanc J-J, Bertault-Valls V, Fatemi M, et al. Mid-term benefits of left univentricular pacing in patients with congestive heart failure. Circulation. 2004;109:1741-1744.

28. Bradley DJ, Bradley EA, Baughman KL, et al. Cardiac resynchronization and death from progressive heart failure: a meta-analysis of randomized controlled trials. JAMA. 2003;289:730-740.

29. Bristow MR, Saxon LA, Boehmer J, et al. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med. 2004;350:2140-2150.

30. Cleland JG, Daubert JC, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005;352:1539-1549.

31. Farwell D, Patel NR, Hall A, et al. How many people with heart failure are appropriate for biventricular resynchronization? Eur Heart J. 2000;21:1246-1250.

32. Bart BA, Boyle A, Bank AJ, et al. Ultrafiltration versus usual care for hospitalized patients with heart failure: the relief for acutely fluid-overloaded patients with decompensated congestive heart failure (RAPD-HF). J Am Coll Cardiol. 2005;46:2043-2046.

33. Costanzo MR, Saltzberg M, O’Sullivan J, et al. Early ultrafiltration in patients with acutely decompensated heart failure and diuretic resistance. J Am Coll Cardiol. 2005;46:2047-2051.

34. Agostini PG, Marenzi GC, Lauri G, et al. Sustained improvement in functional capacity after removal of body fluid with isolated ultrafiltration in chronic cardiac insufficiency; failure of furosemide to provide same results. Am J Med. 1994;96:191-199.

Practice recommendations

Use B-type natriuretic peptide (BNP) levels as an aid not only in the diagnosis of heart failure (HF), but to track its progression as well (A).
Prescribe exercise training for patients with stable heart failure; exercising at 40% to 70% of maximum capacity for 20 to 45 minutes several times a week offers benefits on par with pharmacotherapy (A).
Consider using the Simplified Treatment Intervention to Control Hypertension (STITCH) algorithm for hypertensive patients or those who are at risk of developing HF; this step-care strategy is effective in treating hypertension, a leading cause of HF (C).
Consult a specialist before prescribing both an angiotensin-converting enzyme (ACE) inhibitor and an angiotensin receptor blocker (ARB) for a patient with advanced HF; studies of combination therapy for this patient population have had mixed results (C).

Strength of recommendation (SOR)

Good-quality patient-oriented evidence
Inconsistent or limited-quality patient-oriented evidence
Consensus, usual practice, opinion, disease-oriented evidence, case series

Family physicians are all too familiar with heart failure (HF). This debilitating condition accounts for approximately 3.4 million outpatient visits to US physicians annually,¹ and fully two-thirds of HF patients are cared for by primary care physicians.²

A host of comorbid conditions—coronary artery disease, valvular heart disease, diabetes, dyslipidemia, metabolic syndrome, obesity, chronic renal insufficiency, and hypertension chief among them—contribute to the development of HF.³ Of these, hypertension is the most important factor. In more than 75% of cases, high blood pressure precedes HF,¹ and an individual’s lifetime risk of developing HF is strongly associated with poor blood pressure control.⁴ Hypertension is the most significant controllable factor in the management of HF as well. Because of the nexus between hypertension and HF, we encourage physicians to think of these 2 conditions as a single entity—and to recognize that a reduction of even a few millimeters of mercury can have huge clinical benefits.

FAST TRACK

Hypertension precedes the development of HF more than 75% of the time.

This review, which highlights a recently tested hypertension algorithm along with other recent developments and long-established treatment strategies, will help you do everything possible to slow the progression of this debilitating and deadly disease.

BNP’s increasing role in evaluating heart failure

A diagnosis of HF in patients with known heart disease is based on functionality and symptoms, assessed with the help of 2 classification schemes^5,6 ( TABLE 1 ) and a variety of tests. (Patients who present with the signs and symptoms of HF but no evidence of the comorbid conditions typically associated with it should be screened for other, noncardiac causes—human immunodeficiency virus, hepatitis C, hemochromatosis, hypothyroidism, and substance abuse among them.⁶)

Diagnostic testing. Baseline serum chemistries include a complete blood count, urinalysis, electrolytes, magnesium, blood urea nitrogen, creatinine, and blood glucose levels, and liver and thyroid function tests.

B-type natriuretic peptide (BNP), a homeostatic marker secreted by the heart in an attempt to maintain stable blood pressure and plasma volume and avoid fluid retention, is increasingly recognized as an important aid, not only in diagnosing HF but in gauging its severity, managing symptoms, and determining the prognosis.^7,8 BNP concentrations <80 pg/mL have been found to have a negative predictive value of 98%, and are also highly sensitive (98%) and specific (98%) for the diagnosis of HF.^9,10

Testing may also include a 12-lead electrocardiogram as well as a posterior-anterior/lateral chest x-ray. Echocardiography is often used to evaluate left ventricular function and ejection fraction⁶—a key to establishing whether the patient has systolic (reduced ejection fraction) or diastolic (preserved ejection fraction) HF.

An ejection fraction ≤40% is characteristic of systolic HF, which affects approximately 60% of patients with heart failure¹¹ and is the focus of the following discussion of treatments.

TABLE 1
Classifying heart failure: 2 systems

NEW YORK HEART ASSOCIATION
Class I: No limitation of physical activity; ordinary activity does not cause undue fatigue or dyspnea. Class II: Slight limitation of activity; comfortable at rest, but ordinary physical activity results in fatigue or dyspnea. Class III: Marked limitation in activity. Class IV: Unable to carry on any physical activity without symptoms; symptoms present even at rest.
AMERICAN COLLEGE OF CARDIOLOGY/AMERICAN HEART ASSOCIATION
Stage A: Conditions strongly associated with heart failure (HF); at high risk of HF. No identified structural or functional abnormalities of the pericardium, myocardium, or cardiac valves; no signs or symptoms of HF. Stage B: Structural heart disease strongly associated with HF, but no known signs or symptoms. Stage C: Current or prior symptoms of HF associated with underlying structural heart disease. Stage D: Advanced structural heart disease, with marked symptoms of HF at rest despite maximal medical therapy. Specialized interventions required.
Sources: Criteria Committee of the New York Heart Association. Diseases of the Heart and Blood Vessels–Nomenclature and Criteria for Diagnosis. 6th ed. 1964;⁵ Hunt et al. Circulation. 2005.⁶