Treatment of Heart Failure

Overview

• Heart failure treatment involves understanding diagnostics and classifying the severity using the New York Heart Association (NYHA) classification system.
• Primarily a clinical diagnosis based on symptoms with supporting tests like chest x-ray, BNP levels, echocardiogram, and cardiac catheterization.

Diagnostics Overview

• Chest X-ray: Can show cardiomegaly, pulmonary edema, and pleural effusions.
• BNP (Brain Natriuretic Peptide): Elevated levels suggest stress on heart muscles; used to assess treatment effectiveness.
• Echocardiogram: Gold standard; identifies systolic vs. diastolic heart failure and other heart pathologies.
• Cardiac Catheterization: Determines underlying causes like ischemic heart disease.

NYHA Classification System

• Class 1: Symptoms only with extreme exertion
• Class 2: Symptoms with moderate exertion
• Class 3: Symptoms with mild exertion
• Class 4: Symptoms at rest (most severe)

General Treatment Principles

• Treat underlying diseases: diabetes, hypertension, hyperlipidemia, myocardial infarction, obstructive sleep apnea.
• Lifestyle changes: restrict sodium (< 2g/day) and water (< 2L/day) intake.

Pharmacological Treatment

Renin-Angiotensin-Aldosterone System (RAAS)

• ACE Inhibitors (Class 1): Captopril, Enalopril, Lisinopril, Benzapril.
  • Inhibit ACE enzyme, reduce afterload, preload, and stress on heart.
  • Caution: dry cough and angioedema.
• Angiotensin II Receptor Blockers (ARBs) (Class 1): Losartan, Valsartan, Candesartan.
  • Block angiotensin II actions, similar effects as ACE inhibitors.
• Aldosterone Antagonists (Class 3): Spironolactone, Eplerenone.
  • Used for class 3 heart failure, post-MI remodeling, potassium sparing.
• Entresto (Sacubitril/Valsartan) (Class 3): Combines neprilysin inhibitor with ARB to enhance BNP effects and reduce angiotensin II.

Sympathetic Nervous System

• Beta Blockers (Class 1): Metoprolol, Carvedilol.
  • Reduce heart rate, contractility, and renin release. Contraindicated in decompensated heart failure.
• Digoxin (Class 4): Increases contractility, used when other treatments fail.
• Dobutamine: Used in decompensated heart failure to increase cardiac output.

Diuretics

• Loop Diuretics (Class 2): Furosemide (Lasix).
  • Used to treat fluid overload, pulmonary edema.
• Thiazide Diuretics (Class 2): Hydrochlorothiazide, Metolazone.
  • Often combined with loop diuretics for enhanced effect.

Vasodilators

• Hydralazine (Class 3): Used when ACE inhibitors/ARBs are not tolerated; safe in pregnancy.
• Isosorbide Dinitrate (Class 3): Used for venous dilation, reduces preload.

Decompensated Heart Failure Management

• Use mnemonic LMNOP:
  • L: Lasix (diuretics)
  • M: Morphine for pain management
  • N: Nitrates (e.g., Hydralazine)
  • O: Oxygen supplementation
  • P: Positioning to alleviate fluid overload in lungs

Conclusion

• Treatment involves a combination of medications, lifestyle changes, and addressing underlying conditions.
• Sequential medication use based on patient’s heart failure class and response to treatment.

Resources

• Facebook and Instagram links available in video description for further engagement.