Treatment of Heart Failure

The approach to treatment of heart failure involves applying several principles, depending on its cause and severity:

elimination of the overload primarily responsible for heart failure

improvement of the contractility of the heart muscle

elimination of excess fluid

reduction of cardiac workload by lowering arterial pressure or decreasing the volume of blood returning to the heart

Eliminating or ameliorating the disease that overloaded the heart and eventually led to its failure is the most effective treatment, though only a small number of cases is suitable for this approach. Successful medical or surgical treatment not only can improve the patient's condition but can even cause a gradual regression of cardiac hypertrophy, as shown by appropriate changes in the electrocardiogram and echocardiogram.

To increase the strength of contraction of the failing heart, digitalis and its derivatives are the traditional drug of choice. They can be administered intravenously for acute heart failure and orally over long periods. Several new drugs, administered by injection, have now been introduced; they can produce effective short-term improvement in cases of acute heart failure. At the present time several drugs capable of stimulating cardiac performance when taken orally are being tested. Their long-term safety and effectiveness are as yet uncertain.

Treatment aimed at controlling fluid retention involves two steps. In milder cases restriction of salt intake in the diet may effectively prevent fluid retention and restore prefailure cardiac function. In the majority of cases, however, diuretic drugs provide the most effective treatment for heart failure. Administration of diuretics has an immediate effect and often leads to a dramatic improvement of a patient's condition by controlling dyspnea and eliminating the consequences of fluid retention. It should be noted that fluid retention not only causes symptoms that produce discomfort but also affects unfavorably the function of the heart by inducing some overload, which can be eliminated by diuretic therapy. Such treatment often permits the patient to lead an active life even though the function of the cardiac pump may be permanently impaired.

In the 1970s an extremely effective group of drugs capable of reducing the workload of the heart was introduced. These drugs are known as vasodilators, or afterload reducers. This treatment works either by lowering the blood pressure or by reducing the resistance that the heart pumps against. It differs from the elimination of overload in that the latter treatment is capable of restoring normal

function, whereas the former merely lowers the normal workload. When cardiac workload is reduced, regardless of the cause of heart failure, symptoms may be successfully controlled. This treatment is now widely used in patients with congestive heart failure.

The principal goal of treatment of heart failure is to alleviate symptoms and improve the life-style of patients suffering from serious heart disease. Only treatments successfully correcting the cause of failure, such as surgical correction of valve diseases or management of hypertension, can be considered to cure congestive heart failure. Vasodilator drugs, however, do reduce the annual mortality rate in chronic heart failure. It has not been definitively established whether medical therapy in chronic heart failure not amenable to direct intervention prolongs life.

The need for medical therapy varies widely. In many patients, particularly those with acute heart failure, treatment may be discontinued as the patient recovers from an episode of cardiac failure. In milder cases of chronic heart failure dietary restriction or occasional use of diuretics may be the only treatment needed. In some cases continuous therapy using one or more drug is essential if the patient is to obtain the full benefit of the therapy. There remain patients who are severely disabled despite the best available treatment. These patients have what physicians term end-stage heart failure and are potential candidates for the treatment of last resort, namely, cardiac transplantation.