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Congestive Heart Failure generates more than 11 million physician visits each year and results in more hospitalizations than any other diagnosis for all patients over 65. Proper management of these patients will extend their lives, reduce or delay hospitalizations and result in substantially lower costs of care.

Principles of therapy in chronic heart failure (HF) include the following:

(1) A stable congestion-free state should always be the “background” upon which neurohormonal antagonists are titrated/adjusted. This is achieved by appropriate dosage of maintenance diuretics, a flexible sliding-scale diuretic regimen based upon maintenance of daily weights within a +/- 3 lb. range of “dry” body weight, dietary restriction of sodium in all patients (2,000 mg/d) and dietary restriction of total daily fluid intake in most patients (2 L/d). (2) Anti-remodeling by neurohormonal antagonists (ACEI, beta-blockers, spironolactone) should be advanced at least to doses achieved in clinical mortality trials whenever possible. (3) Maintain optimum ventricular “loading” conditions whenever possible with a) maintenance of weight within +/- 3 lbs. of “dry” goal weight as above, b) normalization of jugular venous pressure, c) maintenance of an edema-free state, d) systolic blood pressure 110-120 mmHg in absence of orthostasis or symptoms

(4) Maintain optimum heart rate (less than 85 at rest ideally and slower in chronic atrial fibrillation). (5) Appropriate “prophylaxis” against sudden death (beta-blockers in all patients; ICDs in appropriately selected patients). (6) Reverse underlying/precipitating causes (non-adherence, ischemia, hypertension, arrhythmias among the commonest).

When managing heart failure, pharmacological therapy should relieve symptoms and signs of congestion and inadequate perfusion along with inhibiting ventricular remodeling, improving quality of life, and prolong survival. Specific agents prescribed for treatment include ACEI inhibitors, beta-blockers, aldosterone antagonists, diuretics, digoxin, anticoagulants, and antiarrhythmics.

Diuretic therapy is recommended to restore and maintain normal volume status in HF patients with clinical evidence of volume overload. In general, the goal in treating chronic HF should be to titrate to the minimum effective dose of diuretic required to control symptoms and volume. Since patients with heart failure often exhibit diuretic “resistance”, they often require high or escalating doses of diuretics as the severity of HF progresses. Excessive use of diuretics however may be harmful in HF as it promotes volume depletion and resultant reflex activation of the sympathetic nervous system and renin-angiotensin system (i.e., excessive diuretic use acts as a “neurohormonal agonist”).

Perhaps the commonest error in chronic heart failure management is to rely too heavily on diuretics for volume and weight control and not to emphasize or insist upon the importance of dietary sodium and fluid restriction. In general,

1) patients with mild volume overload and preserved creatinine clearances may be treated with a thiazide diuretic 2) patients with more severe volume overload, estimated creatinine clearances less than 30 mL/min or persistent edema despite a thiazide require a loop diuretic, usually furosemide.

Diuretics work best if the patient is resting or recumbent for 30-45 minutes after taking the diuretic. This is particularly important in fragile patients who exhibit diuretic refractoriness.

There are not standard target doses of diuretics in HF. The dose of furosemide with truly refractory HF and diuretic resistance may have to be increased to up to 240 mg or more a day in divided doses. Most cardiologists would add low-dose metolazone (a very potent thiazide-like diuretic which acts by a different mechanism) once the dose of furosemide exceeds 120 mg bid. All dosing should be predicated upon daily weight determinations, signs of volume status (JVP, rales, hepatomegaly, edema) and maintenance of acceptable electrolyte concentrations (particularly serum potassium and magnesium).

For more complex HF disease, collaboration with a comprehensive disease management program may be appropriate when 3 or more admissions within the part calendar year; readmission within 60 days of hospitalization for HF; renal insufficiency; uncontrolled hypertension; low output state; diabetes; COPD; NYHA III/IV symptoms; multiple active co-morbidities; history of depression or cognitive impairment; and persistent non-adherence.

References: Hunt SA et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2005 Sep 20;112(12):e154-235.

HFSA of America. Executive Summary: HFSA 2006 Comprehensive Heart Failure Practice Guidelines. J Cardiac Failure 2006:12;10-38

Dec GW. Management of acute decompensated heart failure. Curr Probl Cardiol. 2007;32:321-66.





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All source data for this article has been provided by Vanderbilt Health Services.



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