Nearly 70,000 adults in the US die unnecessarily each year from heart failure, according to an important recent study.
How could this be?
When researchers reviewed the medical records of more than two million Americans with heart failure, they found that the majority of patients with this condition don’t get one or more of the recommended treatments.
The six key therapies (found in guidelines created by the American College of Cardiology and the American Heart Association) that are not being used as often as they should be…*
Beta-blockers. Two of these medications, carvedilol (Coreg) and metoprolol (Toprol-XL), are routinely prescribed for heart-failure patients. The drugs lower blood pressure and have been shown to reverse remodeling, changes in the size/shape of the heart that often accompany heart failure.
Potential problem: Doctors often prescribe too small a dose because patients may experience light-headedness, a too-slow heartbeat and/or other side effects. But studies show that to reduce mortality and hospitalizations, heart-failure patients should take the highest possible dose of these medications, usually about 25 mg of carvedilol twice daily or 200 mg of metoprolol once daily.
My advice: Doctors should first prescribe a low dose, then double it every two to four weeks depending on heart rate and blood pressure. When side effects begin, promptly notify your doctor so the dose can be slightly lowered.
ACE inhibitors. An angiotensin-converting enzyme (ACE) inhibitor, such as lisinopril (Prinivil) or enalapril (Vasotec), should be part of most heart-failure patients’ regimens. These drugs dilate arteries and reduce blood pressure.
Potential problem: An excessive drop in blood pressure is a common side effect of ACE inhibitors.
My advice: If you experience dizziness or fainting, call your doctor. You may need a slightly lower dose. Regular office visits should be scheduled to make sure that your blood pressure is in a healthy range. If you have other side effects, such as headaches, an angiotensin receptor blocker, such as losartan (Cozaar), could be prescribed instead.
Hydralazine/isosorbide dinitrate. For unknown reasons, African-Americans don’t respond as well as Caucasians to conventional treatments (such as ACE inhibitors) for heart failure.
The African-American Heart Failure Trial compared the effects of a placebo with a two-drug combination (BiDil)—hydralazine plus isosorbide dinitrate—in 1,050 patients. The trial was stopped early because the drugs were so clearly effective. Patients taking the combination were 33% less likely to have a first hospitalization from heart failure and 43% less likely to die from any cause.
Potential problem: As many as 40% of patients prescribed hydralazine/isosorbide dinitrate stop taking the drugs because of side effects such as headaches and dizziness.
My advice: African-American heart-failure patients should first try a beta-blocker and ACE inhibitor. If the response is poor, then a small dose of hydralazine/isosorbide dinitrate should be added to the regimen. Side effects should be monitored, and the dose slowly increased.
Aldosterone antagonists. Some doctors prescribe these medications, which are a type of diuretic, only for patients with advanced heart failure. However, new research shows that aldosterone antagonists, such as spironolactone (Aldactone), can also benefit patients with less serious disease. The drugs reduce fluid buildup and improve the heart’s pumping ability.
Potential problem: Doctors tend to underprescribe these medications because of concerns about side effects—particularly hyperkalemia, excess potassium in the blood. This complication can be dangerous and even life-threatening.
My advice: Patients taking these drugs need to have their potassium levels checked regularly—typically one week after starting the medication, again several weeks later, and again after about a month. If potassium levels remain stable, the intervals between blood tests can be extended to three to six months.
Implantable cardioverter defibrillator (ICD). Traditionally, these devices were recommended for heart-failure patients who survived a sudden loss of heart function due to irregularities in the heart’s electrical system. However, research has shown that ICDs, which are implanted just beneath the skin, usually around the left shoulder, also improve long-term survival in patients with other symptoms of heart failure such as a low ejection fraction (the heart’s ability to squeeze).
Potential problem: In rare cases (fewer than 10% of patients), the devices deliver a shock when one isn’t needed. Emotional symptoms, such as anxiety or depression, occur in more than 30% of patients who get the devices—in part due to uncertainty over whether the device will deliver an unnecessary shock.
My advice: If you have an ICD or are anxious about getting one, ask your cardiologist to recommend a support group. Also important: Talk to your cardiologist about steps to take if the device goes off (appropriately or not) several times in a row.
Cardiac resynchronization therapy (CRT). Patients with moderate to severe heart failure who respond well to medications but still have symptoms—particularly those with left bundle branch block, a blockage in the electrical pathway of the heart—are good candidates for CRT. In patients who receive it, risk of dying from heart failure is reduced by about 35%. With CRT, electrodes are inserted into different parts of the heart, and a small battery pack to power the electrodes that regulate heartbeat is implanted under the collarbone.
Potential problem: In rare cases, infection occurs in the CRT device—and in the ICD device, which is often combined with CRT.
My advice: Ask your cardiologist if you are a candidate for CRT or CRT/ICD treatment.
Heart failure (also known as congestive heart failure) occurs when the heart isn’t able to pump enough blood to meet the body’s needs for blood and oxygen. Most cases occur in people with other cardiovascular diseases, such as high blood pressure and/or coronary artery disease, which impair the heart’s normal functions. Symptoms of heart failure include fatigue, shortness of breath, a persistent cough and/or swelling in the legs, ankles and feet.
*To read more about the recommended therapies, go to www.Heart.org/quality and click on “Get with the Guidelines: Heart Failure.”
Source: Edward K. Kasper, MD, director of clinical cardiology and the E. Cowles Andrus Professor of Cardiology at The Johns Hopkins University School of Medicine/Johns Hopkins Hospital in Baltimore. He is the author, with Mary Knudson, of Living Well with Heart Failure (Johns Hopkins University).