- Email: [email protected]
MY APPROACH to treating heart failure with reduced ejection fraction
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24 (2014) 367–368
Available online at www.sciencedirect.com
www.elsevier.com/locate/tcm
MY APPROACH
MY APPROACH to treating heart failure with reduced ejection fraction
Barry H. Greenberg, MD The management of patients with heart failure with reduced ejection fraction (HFrEF) has advanced considerably over the past several decades. Insights into basic underlying mechanisms and the development of new therapies that favorably alter the clinical course now provide a variety of therapeutic options that allow patients with HFrEF to both live longer and experience a much better quality of life. My approach to managing patients with HFrEF is outlined below:
Be certain that heart failure is the cause of the patient’s signs and symptoms. Establish the etiology wherever possible. Define severity and risk. Recognize and manage comorbidities that influence the clinical course. Initiate and optimize medical therapy. Assess whether the patient is a candidate for an implantable cardioverter defibrillator (ICD) and/or cardiac resynchronization therapy (CRT). Consider advanced therapies in selected patients.
Most patients with HFrEF experience signs and symptoms of congestion at some point in their clinical course. Loop diuretics (eg, furosemide, bumetanide, torsemide) are highly effective in treating volume overload. Occasionally, an
additional diuretic (eg, metolazone or a thiazide diuretic) will be added to the regimen. While very effective in treating refractory congestion, this approach should be used with a great deal of caution due to both the uncertainty of the magnitude of response and the electrolyte abnormalities (eg, hypokalemia) that it causes. My practice is to add digoxin to the regimen in patients who remain symptomatic (even if they are in sinus rhythm), particularly when substantial cardiomegaly, a rapid heart rate, or an S3 is present. Neurohormonal blocking has emerged as the cornerstone of therapy for patients with HFrEF over the past 3 decades, based largely on their ability to prevent or reverse maladaptive cardiac remodeling. The three classes of drug that are used are:
Angiotensin converting enzyme (ACE) inhibitors Beta blockers (BBs) Mineralocorticoid receptor antagonists (MRAs)
Although guideline recommendations suggest initiation of ACE inhibitors and BBs before MRAs, in practice the order and timing depends on the clinical situation. Factors influencing the use of these agents include:
Degree of decompensation and/or volume load Blood pressure Renal function Presence of electrolyte abnormalities
An angiotensin receptor blocker (ARB) may be substituted for an ACE inhibitor if the patient is experiencing side effects that are more common with the ACE inhibitor (eg, cough or angioneurotic edema). Occasionally, an ACE inhibitor and ARB are used in the same patient, but, in that case, MRAs should be avoided to protect against the development of hyperkalemia. For ACE inhibitors and MRAs, there does not appear to be sufficient evidence to recommend one drug over another. For BBs, the recommendation is to use only agents that have been used successfully in clinical trials (ie, carvedilol, metoprolol
First published on PracticeUpdate on June 16, 2014. Republished with permission.
http://dx.doi.org/10.1016/j.tcm.2014.06.008 1050-1738/& 2014 Published by Elsevier Inc.
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succinate, and bisoprolol). For all of the neurohormonal blocking agents, up-titration to doses shown to be effective in clinical trials should be attempted whenever possible. With aggressive use of medical therapy, many patients experience relief of symptoms as well as improvement in their EF. Those who continue to exhibit a reduced EF should be considered for an ICD and/or CRT, if the QRS is prolonged. Patients with a QRS 4150 msec and LBBB pattern on their ECG are the most likely to benefit from CRT, but guideline recommendations allow for clinical judgment to be used in other settings. While most patients improve with the combination of medical and device therapies, some do not and they should be considered for advanced therapy options including:
Transplantation Mechanical circulatory support Palliative care and/or hospice
The perception that a patient might be entering an advanced stage of disease is a good indication for referral to a heart failure program that offers access to therapies for end-stage disease such as cardiac transplantation and/or left ventricular assist devices. One of the more difficult aspects of patient management is to determine whether a patient should be considered for advanced care. While each patient should be considered individually, factors that enter into the decision-making process include:
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Extent to which EF is reduced or the heart is dilated Frequent or increasing number of hospitalizations for decompensation Symptomatic limitation Inability to up-titrate neurohormonal blocking agents to at least 50% of their recommended dose
Symptomatic limitation is often difficult to quantify in patients and may be influenced by non-cardiac factors. Formal assessment of exercise capacity using the 6-minute walk test or cardiopulmonary exercise test is often helpful in defining both the extent and cause of a patient’s symptomatic limitation. Overall, while outcomes for HFrEF patients are substantially more favorable now than in the past, it is important to establish a plan for evaluation and treatment in such patients that incorporates the approaches listed above. The treatment strategies should be integrated so that the primary care physician, cardiologist, heart failure specialist, and electrophysiologist are involved in the management of these patients. Distinguished Professor of Medicine, University of California, San Diego (UCSD) School of Medicine; Director, Advanced Heart Failure Treatment Program, Sulpizio Cardiovascular Center UCSD Healthcare System, La Jolla, California E-mail address: [email protected]
E N D S I N
C
A R D I O V A S C U L A R
M
E D I C I N E
24 (2014) 367–368
Available online at www.sciencedirect.com
www.elsevier.com/locate/tcm
MY APPROACH
MY APPROACH to treating heart failure with reduced ejection fraction
Barry H. Greenberg, MD The management of patients with heart failure with reduced ejection fraction (HFrEF) has advanced considerably over the past several decades. Insights into basic underlying mechanisms and the development of new therapies that favorably alter the clinical course now provide a variety of therapeutic options that allow patients with HFrEF to both live longer and experience a much better quality of life. My approach to managing patients with HFrEF is outlined below:
Be certain that heart failure is the cause of the patient’s signs and symptoms. Establish the etiology wherever possible. Define severity and risk. Recognize and manage comorbidities that influence the clinical course. Initiate and optimize medical therapy. Assess whether the patient is a candidate for an implantable cardioverter defibrillator (ICD) and/or cardiac resynchronization therapy (CRT). Consider advanced therapies in selected patients.
Most patients with HFrEF experience signs and symptoms of congestion at some point in their clinical course. Loop diuretics (eg, furosemide, bumetanide, torsemide) are highly effective in treating volume overload. Occasionally, an
additional diuretic (eg, metolazone or a thiazide diuretic) will be added to the regimen. While very effective in treating refractory congestion, this approach should be used with a great deal of caution due to both the uncertainty of the magnitude of response and the electrolyte abnormalities (eg, hypokalemia) that it causes. My practice is to add digoxin to the regimen in patients who remain symptomatic (even if they are in sinus rhythm), particularly when substantial cardiomegaly, a rapid heart rate, or an S3 is present. Neurohormonal blocking has emerged as the cornerstone of therapy for patients with HFrEF over the past 3 decades, based largely on their ability to prevent or reverse maladaptive cardiac remodeling. The three classes of drug that are used are:
Angiotensin converting enzyme (ACE) inhibitors Beta blockers (BBs) Mineralocorticoid receptor antagonists (MRAs)
Although guideline recommendations suggest initiation of ACE inhibitors and BBs before MRAs, in practice the order and timing depends on the clinical situation. Factors influencing the use of these agents include:
Degree of decompensation and/or volume load Blood pressure Renal function Presence of electrolyte abnormalities
An angiotensin receptor blocker (ARB) may be substituted for an ACE inhibitor if the patient is experiencing side effects that are more common with the ACE inhibitor (eg, cough or angioneurotic edema). Occasionally, an ACE inhibitor and ARB are used in the same patient, but, in that case, MRAs should be avoided to protect against the development of hyperkalemia. For ACE inhibitors and MRAs, there does not appear to be sufficient evidence to recommend one drug over another. For BBs, the recommendation is to use only agents that have been used successfully in clinical trials (ie, carvedilol, metoprolol
First published on PracticeUpdate on June 16, 2014. Republished with permission.
http://dx.doi.org/10.1016/j.tcm.2014.06.008 1050-1738/& 2014 Published by Elsevier Inc.
368
T
R E N D S I N
C
A R D I O V A S C U L A R
succinate, and bisoprolol). For all of the neurohormonal blocking agents, up-titration to doses shown to be effective in clinical trials should be attempted whenever possible. With aggressive use of medical therapy, many patients experience relief of symptoms as well as improvement in their EF. Those who continue to exhibit a reduced EF should be considered for an ICD and/or CRT, if the QRS is prolonged. Patients with a QRS 4150 msec and LBBB pattern on their ECG are the most likely to benefit from CRT, but guideline recommendations allow for clinical judgment to be used in other settings. While most patients improve with the combination of medical and device therapies, some do not and they should be considered for advanced therapy options including:
Transplantation Mechanical circulatory support Palliative care and/or hospice
The perception that a patient might be entering an advanced stage of disease is a good indication for referral to a heart failure program that offers access to therapies for end-stage disease such as cardiac transplantation and/or left ventricular assist devices. One of the more difficult aspects of patient management is to determine whether a patient should be considered for advanced care. While each patient should be considered individually, factors that enter into the decision-making process include:
ME
D I C I N E
24 (2014) 367–368
Extent to which EF is reduced or the heart is dilated Frequent or increasing number of hospitalizations for decompensation Symptomatic limitation Inability to up-titrate neurohormonal blocking agents to at least 50% of their recommended dose
Symptomatic limitation is often difficult to quantify in patients and may be influenced by non-cardiac factors. Formal assessment of exercise capacity using the 6-minute walk test or cardiopulmonary exercise test is often helpful in defining both the extent and cause of a patient’s symptomatic limitation. Overall, while outcomes for HFrEF patients are substantially more favorable now than in the past, it is important to establish a plan for evaluation and treatment in such patients that incorporates the approaches listed above. The treatment strategies should be integrated so that the primary care physician, cardiologist, heart failure specialist, and electrophysiologist are involved in the management of these patients. Distinguished Professor of Medicine, University of California, San Diego (UCSD) School of Medicine; Director, Advanced Heart Failure Treatment Program, Sulpizio Cardiovascular Center UCSD Healthcare System, La Jolla, California E-mail address: [email protected]