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The ABCs of managing systolic heart failure: Past, present, and future

Cleveland Clinic Journal of Medicine. 2016 October;83(10):753-765 | 10.3949/ccjm.83a.16006
October 1, 2016|Cleveland Clinic Journal of Medicine
Ike S. Okwuosa, MD;Oluseyi Princewill, MD, MPH;Chiemeke Nwabueze, MD;Lena Mathews, MD;Steven Hsu, MD;Nisha A. Gilotra, MD;Sabra Lewsey, MD, MPH;Roger S. Blumenthal, MD;Stuart D. Russell, MD
Author and Disclosure Information

Ike S. Okwuosa, MD
Division of Cardiology, The Johns Hopkins Hospital, Baltimore, MD

Oluseyi Princewill, MD, MPH
Division of Cardiology, The Johns Hopkins Hospital, Baltimore, MD

Chiemeke Nwabueze, MD
Georgetown University School of Medicine, Washington, DC

Lena Mathews, MD
Division of Cardiology, The Johns Hopkins Hospital, Baltimore, MD

Steven Hsu, MD
Division of Cardiology, The Johns Hopkins Hospital, Baltimore, MD

Nisha A. Gilotra, MD
Director, Heart Failure Bridge Clinic, Advanced Heart Failure/Transplant Cardiology, Division of Cardiology; Assistant Professor of Medicine, The Johns Hopkins Hospital, Baltimore, MD

Sabra Lewsey, MD, MPH
Division of Cardiology, The Johns Hopkins Hospital, Baltimore, MD

Roger S. Blumenthal, MD
Division of Cardiology, The Johns Hopkins Hospital, Baltimore, MD

Stuart D. Russell, MD
Division of Cardiology, The Johns Hopkins Hospital, Baltimore, MD

Address: Ike Stanley Okwuosa, MD, The Johns Hopkins Hospital, 1800 Orleans Street, Zayed 7125, Baltimore, MD 21287; isokwuosa@gmail.com

ABSTRACTHeart failure management is complex and constantly evolving. The American College of Cardiology and the American Heart Association (ACC/AHA) last issued evidence-based guidelines in 2013, and since then, new drugs and devices have been developed. This review presents an evidence-based approach to current heart failure management.

KEY POINTS

  • Most patients with systolic heart failure (also called heart failure with reduced ejection fraction) should receive either an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker. Most should also receive a beta-blocker (carvedilol, metoprolol succinate, or bisoprolol).
  • If symptoms persist or progress despite these treatments, an aldosterone receptor antagonist (spironolactone or eplerenone) is recommended.
  • Since the publication of the ACC/AHA guidelines in 2013, the combination of sacubitril and valsartan has been approved, as has ivabradine.
  • Patients with advanced heart failure should be identified early for consideration of resynchronization therapy, an implantable cardiac defibrillator, digoxin, a left ventricular assist device, or heart transplant.
  • B-type natriuretic peptide levels can be used to guide therapy.

Exercise

Patients with heart failure routinely experience a decline in functional capacity. This decline manifests as reduced exercise tolerance and poor quality of life, usually resulting in a physician recommendation to rest and paradoxical deconditioning and possible progression of symptoms.

Several studies have shown that cardiac rehabilitation has improved outcomes in heart failure patients.48 Cardiac rehabilitation is a supervised program that helps patients with exercise training, healthy living, education, and psychosocial counseling.

HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) is the largest randomized trial performed to determine whether aerobic exercise training reduces all-cause mortality or all-cause hospitalization and improves quality of life in patients with stable heart failure.49 Although the reduction in end points was initially not statistically significant, after adjusting for highly prognostic predictors of poor outcomes (cardiopulmonary exercise time, left ventricular ejection fraction, atrial fibrillation, and depression), exercise training was found to reduce the incidence of all-cause mortality or all-cause hospitalization by 11% (P = .03).49

Recommendations. Based on the results of HF-ACTION and several smaller studies, the ACC/AHA guidelines give exercise training a class IA recommendation as a safe and effective activity for patients with heart failure who are able to participate, to improve functional status.1 A class IIA recommendation is given to cardiac rehabilitation for the improvement of functional capacity, exercise duration, quality of life, and mortality rates.1

End-stage heart failure: Recognition

Despite adequate titration of goal-directed medical therapy, a portion of patients with heart failure with reduced ejection fraction ultimately progress to stage D, also termed “advanced” heart failure. The 5-year survival rate for patients with heart failure overall is 50%, but the 1-year mortality rate for those with advanced heart failure exceeds 50%.50

Because the high rates of morbidity and mortality can potentially be lowered, recognition of heart failure disease progression is imperative so that patients can be promptly referred for therapies such as inotropic infusion, mechanical circulatory support, and cardiac transplant, as well as end-of-life care such as hospice.1

The ACC/AHA1 have published clinical events and findings useful in identifying patients with advanced heart failure:

  • Two or more hospitalizations or emergency department visits for heart failure in the past year
  • Progressive deterioration in renal function (eg, elevation in creatinine or blood urea nitrogen)
  • Weight loss without other cause
  • Intolerance to ACE inhibitors due to hypotension or worsening renal function
  • Inability to tolerate beta-blockers due to worsening heart failure or hypotension
  • Systolic blood pressure often below 90 mm Hg
  • Persistent dyspnea with dressing or bathing requiring rest
  • Inability to walk one block on level ground due to dyspnea or fatigue
  • Recent need to escalate diuretics to maintain volume status, often reaching daily dose equivalent to furosemide more than 160 mg/day or use of supplemental metolazone
  • Progressive decline in serum sodium, usually to below 133 mmol/L
  • Frequent shocks from implanted cardiac defibrillator.

End-stage heart failure: Left ventricular assist devices

For patients with refractory heart failure despite optimal medical management, advanced therapies such as heart transplant or ventricular assist devices have been proven to be durable options. These mechanical circulatory support devices “unload” the diseased ventricle and maintain cardiac output to vital organs.51 They were initially designed as temporary support to allow ventricular recovery or as a bridge to cardiac transplant. However, they have also evolved into permanent (“destination”) therapy.52

REMATCH (the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive HF trial) was the landmark study that showed that left ventricular assist device implantation resulted in a survival benefit and an improved quality of life in patients with advanced heart failure ineligible for cardiac transplant, compared with medical management.50 Implantation of a left ventricular assist device was associated with a 27% absolute reduction in the 1-year mortality rate.50

Since the National Institutes of Health’s artificial heart program was launched in 1964, there has been tremendous progress in the development of mechanical circulatory devices.50 The results of REMATCH were promising, but the 2-year survival rate was still only 23%, leaving a lot to be desired.

The HeartMate II (Thoratec) trial compared an axial continuous-flow device vs the previously established pulsatile left ventricular assist device, and noted a 2-year survival of 58% with the continuous flow device vs  24% with the pulsatile device (P = .008).53

ADVANCE (Evaluation of the HeartWare Left Ventricular Assist Device for the Treatment of Advanced Heart Failure) showed similar efficacy of the HVAD (Heartware), a centrifugal continuous-flow LVAD currently in use.54

The next generation of continuous-flow left ventricular assist devices are currently in clinical trials in the United States and include the axial flow MVAD (Heartware) and centrifugal flow Heartmate III (Thoratec).

We emphasize the importance of early identification of patients with advanced disease who may qualify for and benefit from such therapies.

The management of heart failure is evolving. In the 1960s, the standard heart failure medical regimen included digoxin, diuretics, and the recommendation of rest. This contrasts with the current era, in which medical regimens include neurohormonal blockade, diuretics, and the promotion of physical activity.55 Since the publication of the 2013 heart failure guidelines, new medical and device options have emerged that have been proven to either improve survival or reduce hospitalizations. The development of clinical guidelines promotes evidence-based practice and overcomes the inertia of practice patterns based on anecdotal evidence.

Several approaches to the management of heart failure have been recommended. A major effort should be made to identify those at risk for heart failure (stage A) and to implement risk factor modification. Treatment of hypertension, diabetes mellitus, and dyslipidemia decreases the risk of heart failure.1

Figure 1. An algorithm for managing heart failure with reduced ejection fraction.

For patients with evidence of structural heart disease with and without symptoms, Figure 1 summarizes a guideline approach to the management of heart failure. It should be stressed that guidelines are meant to guide management, but do not serve as a substitute for sound clinical judgment.

Heart failure is the common final pathway of all cardiac pathology, and understanding the neurohormonal response and maladaptive physiology has led to the development of novel therapeutics and devices. At present, the field of cardiology may not be able to remove the “failure” from heart failure, but we can make every effort to prevent failure of treatment delivery and reduce resource utilization and morbidity associated with this syndrome.

Acknowledgments: We would like to thank Chankya Dahagam and Cynthia Obenwa for their valuable contribution in the preparation of this manuscript.

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