Therapeutic Goals in Heart Failure (HF)
Reducing morbidity, progression of disease, and the mortality associated with HF are the three major goals, along with simultaneous improvement of function (activities of daily living) and quality of life.
Management of Co-factors and Co-morbidities
The causes of HF are in interaction with its own complications, often as a vicious cycle of co-dependent conditions. Management includes:
- Lifestyle alteration, including weight management, smoking cessation, strict glycemic control (in diabetics), and supervised exercise.
- Management of hypertension, using a four-part therapy regimen of a 1) beta blocker, 2) ACE inhibitor, 3) an angiotensin II receptor blocker (ARB), and 4) a diuretic (“potassium-sparing” mineralocorticoid receptor antagonist–MRA).
Beta blockers can also relieve angina symptoms. Prior to MRA administration, a serum potassium should be obtained to preclude the risk of hyperkalemia.
- Coronary atherosclerosis: The dominant cause of HF, should be treated with anti-angina drugs and lipid-altering statins; revascularization can improve coronary atherosclerosis and with it, heart failure.
- Renovascular disease (renal hypertension): as a complication of coronary artery disease, besides with use of anti-hypertensive therapy (above), might also benefit from revascularization (coronary stenting or bypass).
- Whether valvular disease is the cause for HF or a complication (mitral and tricuspid regurgitation), surgical correction of valve stenosis or regurgitation will improve heart function, mitigating heart failure.
- Any arrhythmias that accompany HF, such as tachycardia, atrial flutter, or atrial fibrillation, which can prolong and complicate HF, should be resolved. Antiarrhythmic drugs should be used with great caution due to their risk of actually provoking arrhythmia. Reversion to sinus rhythm and slowing down tachycardia can be done via implantable cardiac devices to prevent sudden cardiac death, which has been proven to be superior to antiarrhythmics in reducing mortality.
Since much of the treatment is designed to prevent disease progression, frequent and serial monitoring is part of the therapeutic strategy.
Renal function (via serum creatinine and BUN), surveillance for arrhythmia (via ECG), and identifying worsening volume overload and cardiac dysfunction (via echocardiography and chest X-rays) should be done routinely, based on a schedule individualized for a patient’s particular level of disease and compromise to his or her quality of life and activities of daily living.