Heart failure (HF) is a disorder in the structure or function of the heart that prevents it from maintaining adequate oxygen supply to other tissue. It manifests with symptoms and signs of damage to almost all target organs. The most common cause is damage of the systolic function of the left ventricle, but causes include disrupted diastolic function, valvular diseases, pericardial and endocardial diseases, and heart rhythm disorders. The diagnosis of HF can be established using both invasive and non-invasive techniques. The goal of HF treatment is to reduce the symptoms and signs of the disease, reduce rehospitalization, and improve the quality and length of the patient’s life. Three neurohormonal antagonists play a key role in the treatment: angiotensin-converting enzyme inhibitors (or angiotensin receptor blockers), beta-blockers, and mineralocorticoid receptor antagonists. Refractory HF in the terminal phase can be treated with heart transplants and cardiac support pumps, which can be uni- or biventricular and either temporary or permanent.
Heart failure (HF) can be defined as a disorder in the structure or function of the heart which, despite normal pressure flow, prevents it from maintaining adequate oxygen supply for normal tissue metabolism. (
When diagnosing HF, in addition to chest X-ray, a 12-lead ECG is also needed to determine heart rhythm as well as the QRS complex width (in order to make prognostic estimates but also for indication for the implantation of resynchronizing electrostimulators). Transthoracic echocardiography is the basic method for assessment of the myocardium and valves. (
The goal of HF treatment is to reduce the symptoms and signs of the disease, reduce rehospitalization, and improve the quality and length of the patient’s life. Three neurohormonal antagonists play a key role in the treatment: angiotensin-converting enzyme (ACE) inhibitors (or angiotensin receptor blockers), beta-blockers, and mineralocorticoid receptor antagonists (
| RECOMMENDATIONS | Class of recommendation | Level of evidence |
|---|---|---|
| An ACE inhibitor is recommended, in addition to beta-blocker, for all patients with an EF ≤40% to reduce the risk of HF hospitalization and the risk of premature death |
I |
A |
| A beta-blocker is recommended in addition to an ACE inhibitor (or ARB if ACE i not tolerated) for all patients with an EF ≤40% to reduce the risk od HF hospitalization and the risk of premature death |
I |
A |
| An MRA is recommended for all patients with persisting symptoms (NYHA class II-IV) and an EF ≤35% despite treatment with an ACE inhibitor (or ARB if ACE i not tolerated) and a beta-blocker to reduce the risk of HF hospitalization and the risk of premature death | I | A |
ACE = angiotensin-converting enzyme, ARB= angiotensin receptor blocker, EF= ejection fraction; HF= heart failure, MRA = mineralocorticoid receptor antagonist, NYHA = New York Heart Association. Adapted from: Eur Heart J. 2012;33:1787-847.
Angiotensin-converting enzyme (ACE) inhibitors have been shown to improve the signs and symptoms of HF, reduce rehospitalization, and improve survival rates, and should thus be introduced as soon as the diagnosis is established. Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS) that included patients with severe HF found a 27% reduction in mortality, while the Studies of Left Ventricular Dysfunction (SOLVD) on patients with mild to moderate HF symptoms showed a 16% reduction in mortality. (
Beta-blockers are a heterogeneous group of medications and can be classified as non-selective and selective. Metoprolol, carvedilol, and bisoprolol have been shown to reduce total mortality, rehospitalization, and left ventricle dysfunction (LVEF, 35 – 40%). (
There have been numerous studies on treatment of HF using these medications. The most important are: Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS), Cardiac Insufficiency Bisoprolol Study II (CIBIS II), and Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MEIT-HF). More than 90% of patients received these medications in addition to ACE inhibitors. (
Aldosterone receptor blockers have been found effective in treating patients with systolic HF. Two basic studies, Randomized Aldactone Evaluation Study (RALES) and Epleronon in Mild Patients Hospitalization and Survival Sudy in Heart Failure (EMPHASIS-HF) showed a significant reduction in mortality and rehospitalization, at approximately 35%. These medications can cause hypercalcemia and require renal function monitoring. (
In addition to the above medication, HF is also treated with angiotensin receptor antagonists (most commonly when ACE cause coughing), and ivabradine in patients with a sinus rhythm and EF of <35% when beta-blockers do not reduce the frequency below 70/min. (
As opposed to HF with impaired systolic function, no medication has yet been shown to be effective in patients with a preserved systolic function.
Other than with medication, these patients can also be treated with medical device implantation, such as cardioversion defibrillators for treating patients with ventricular rhythm disorders, resynchronization therapy in patients with lowered ejection fraction, and QRS >120ms. (
Thanks to the development of medicine and technology, many very active treatment methods are available to these patients today, resulting in not only improved quality of life but also in longer lives as well.