Heart Failure: Treatment
University's Advanced Heart Failure Center
1350 Walton Way
Augusta, GA 30901-2629
Hours: 8 a.m.-4:30 p.m.
Managing Triggers of Heart Failure Symptoms
Whenever heart failure worsens, whether quickly or chronically over time, various factors must be considered as the cause:
- Dietary indiscretion. Sometimes as little as eating a sausage or some sauerkraut with a high sodium content is enough to precipitate an acute episode. Failure to comply with fluid and salt restrictions must be considered whenever heart failure worsens.
- Alcohol. Depending on the severity of a patient's heart failure, one or more drinks may suddenly worsen symptoms.
- Medication compliance. Patients may forget or purposely skip a medication, or they may not be able to afford or have access to medications.
- Angina or heart attack. Worsening of coronary artery disease may make the heart muscle less able to pump enough blood.
- Arrhythmias. Increases in the heart rate, or a slowing of the heart rate below normal, may also affect the ability of the heart to function. Likewise, an irregular heart rhythm such as atrial fibrillation may cause a flare-up.
- Anemia. It is unclear whether anemia causes heart failure or is a symptom of heart failure. Some anemias may be treated with iron replacement therapy. A more significant anemia can cause a worsening of heart failure and should be treated promptly.
Many different medications are used in the treatment of heart failure. They include:
- ACE inhibitors
- Beta blockers
- Aldosterone blockers
- Hydralazine and nitrates
- Aspirin and warfarin
- ACE Inhibitors
ACE inhibitors are among the most important drugs for treating patients with heart failure. ACE inhibitors open blood vessels and decrease the workload of the heart. They are used to treat high blood pressure, but can also help improve heart and lung muscle function. ACE inhibitors are particularly important for patients with diabetes, because they also help slow the progression of kidney disease.
Surgery and Devices
Revascularization helps to restore blood flow to heart affected by coronary artery disease. It can treat blocked arteries in patients with coronary artery disease and angina, and may help select patients with heart failure who have these conditions. Techniques include coronary artery bypass graft (CABG) and angioplasty usually with stenting (also called percutaneous coronary intervention [PCI]).
CABG is a traditional type of open heart surgery. Angioplasty is a less-invasive procedure that uses a catheter to inflate a balloon inside the artery. A metal stent may also be inserted during an angioplasty procedure.
Pacemakers, also called pacers, help regulate the heart's beating action, especially when the heart beats too slowly. BVPs are a special type of pacemaker used for patients with heart failure. Because BVPs help the heart's left and chambers to beat in a more coordinated fashion, this treatment is called cardiac resynchronization therapy (CST).
BVPs are recommended for patients with heart failure that is not controlled with medication therapy and who have evidence of left-bundle branch block on their EKG. Left-bundle branch block is a condition in which the electrical impulses in the heart do not follow their normal pattern, causing the heart to pump inefficiently.
Implantable Cardioverter Defibrillators (ICDs)
Patients with enlarged hearts are at risk for having serious cardiac arrhythmias (abnormal heartbeats) that are associated with sudden death. Implantable cardioverter defibrillators (ICDs) can quickly detect life-threatening arrhythmias. The ICD is designed to convert any abnormal heart rhythm back to normal by sending an electrical shock to your heart. This action is called defibrillation. This device can also work as a pacemaker.
Patients with ICDs need to avoid certain types of electronic devices that can disrupt the device. They may also need to avoid certain types of medical and imaging procedures. It is important to talk with your doctor about any questions you have about living with an ICD. Be sure to let your doctor know if you feel anxious or depressed. It's not uncommon for patients with ICDs to experience these emotions, and psychological support is important for both patients and their families.
In recent years, certain ICD models and biventricular pacemaker defibrillators have been recalled by the manufacturers because of circuitry flaws. However, doctors stress that the chance of an ICD or pacemaker saving a person's life far outweigh the possible risks of these devices failing.
Ventricular Assist Devices
Ventricular assist devices are mechanical devices that help improve pumping actions. They are used as a bridge to transplant for patients who are on medications but still have severe symptoms and are waiting for a donor heart. In some cases, they may delay the need for a transplant. Therefore, they may be used as short-term (less than 1 week) or longer term support.
Ventricular assist devices include:
- LVADs are used for patients whose heart beat has slowed dangerously, to help take over the pumping action of the failing heart. Until recently, these machines required that patients remain in the hospital. Smaller battery-powered implanted LVAD units are now allowing many patients to leave the hospital while they wait for a transplant.
- Intra-aortic balloon pumps (IABP) are helpful for temporarily maintaining heart function in patients with left-side failure who are waiting for transplants, and for those who develop a sudden and severe deterioration of heart function. The IABP is an implanted thin balloon that is usually inserted into the artery in the leg and threaded up to the aorta. Its pumping action is generating by inflating and deflating the balloon at certain rates. Patients with balloon pumps must stay in the hospital in bed in an intensive care unit.
- Fully implanted miniature artificial pumps that assist the heart are also being tested.
The risks and complications involved with many of these devices include bleeding, blood clots, and right-side heart failure. Infections are a particular hazard.
Up to half of patients hospitalized for heart failure are back in the hospital within 6 months. Many people return because of lifestyle factors, such as poor diet, failure to comply with medications, and social isolation.
Programs that offer intensive follow-up to ensure that the patient complies with lifestyle changes and medication regimens at home can reduce rehospitalization and improve survival. Patients without available rehabilitation programs should seek support from local and national heart associations and groups. A strong emotional support network is also important.
Medicare recently approved cardiac rehabilitation for some patients with heart failure. Ask your doctor if a program near you may be appropriate.
Monitoring Weight Changes
Patients should weigh themselves each morning and keep a record. Any changes are important:
A sudden increase in weight of more than 2 to 3 pounds may indicate fluid accumulation and should prompt an immediate call to the doctor.
Rapid wasting weight loss over a few months is a very serious sign and may indicate the need for intervention.
Sodium (Salt) Restriction
All patients with heart failure should limit their sodium (salt) intake to less than 2,400 mg a day. (Check with your doctor for exact sodium limits.) DO NOT add salt to cooking and meals, and avoid foods high in sodium. These salty foods include ham, bacon, hot dogs, lunch meats, prepared snack foods, dry cereal, cheese, canned soups, soy sauce, and condiments. Some patients may need to reduce the amount of water they consume. People with high cholesterol levels or diabetes require additional dietary precautions.
Here are some tips to lower your salt and sodium intake:
- Look for foods that are labeled "low-sodium," "sodium-free," "no salt added," or "unsalted." Check the total sodium content on food labels. Be especially careful of canned, packaged, and frozen foods. A nutritionist can teach you how to understand these labels.
- DO NOT cook with salt or add salt to what you are eating. Try pepper, garlic, lemon, or other spices for flavor instead. Be careful of packaged spice blends as these often contain salt or salt products (like monosodium glutamate, MSG) or too much potassium.
- Avoid processed meats (particularly cured meats, bacon, hot dogs, sausage, bologna, ham, and salami).
- Avoid foods that are naturally high in sodium, like anchovies, nuts, olives, pickles, sauerkraut, soy and Worcestershire sauces, tomato and other vegetable juices, and cheese.
- Take care when eating out. Stick to steamed, grilled, baked, boiled, and broiled foods with no added salt, sauce, or cheese.
- Use oil and vinegar, rather than bottled dressings, on salads.
- Eat fresh fruit or sorbet when having dessert.
People with heart failure used to be discouraged from exercising. Now, doctors think that exercise, when performed under medical supervision, is extremely important for stable patients. The AHA recommends exercise (or regular physical activity) as safe and effective for patients with heart failure who are able to participate. Studies have reported that patients with stable conditions who engage in regular moderate exercise (three times a week) have a better quality of life and lower mortality rates than those who do not exercise. However:
- Exercise is not appropriate for all patients with heart failure. If you have heart failure, always consult your doctor before starting an exercise program.
- People who are approved for, but not used to, exercise should start with 5 to 15 minutes of easy exercise with frequent breaks. Although the goal is to build up to 30 to 45 minutes of walking, swimming, or low-impact aerobic exercises three to five times every week, even shorter times spent exercising are useful.
Studies report benefits from specific exercises:
- Progressive strength training may be particularly useful for patients with heart failure since it strengthens muscles, which commonly deteriorate in this disorder. Strength training typically uses light weights, weight machines, or even the body's weight (leg raises or sit-ups, for example). Even performing daily handgrip exercises can improve blood flow through the arteries.
- Patients who exercise regularly using supervised treadmill and stationary-bicycle exercises can increase their exercise capacity. Exercising the legs may help correct problems in heart muscles. Exercise has also been associated with reduced inflammation in blood vessels.
Some people with severe heart failure need periods of bed rest. To reduce congestion in the lungs, the patient's upper body should be elevated. For most patients, resting in an armchair is better than lying in bed. Relaxing and contracting leg muscles are important to prevent clots. As the patient improves, a doctor will progressively recommend more activity.
Stress reduction techniques, such as meditation and relaxation response methods, may have direct physical benefits. Anxiety can cause the heart to work harder and beat faster.
The goal of palliative care is to help the patient with a serious illness feel better. It prevents or treats symptoms and side effects of disease and treatments.
Palliative care can help treat symptoms such as pain, shortness of breath, trouble sleeping, and loss of appetite. Palliative care also treats emotional, social, practical, and spiritual problems that illness brings up. When the patient feels better in these areas, he or she has an improved quality of life.
Palliative care can be given at the same time as treatments meant to cure or treat the disease. You may get palliative care when heart failure is diagnosed, throughout treatment, during follow-up, and at the end of life.
Any provider can give palliative care, but some specialize in it. Palliative care may be given by a team of doctors, nurses, registered dietitians, social workers, psychologists, massage therapists, and chaplains. It may be offered by hospitals, home health agencies, or long-term care facilities.
Both palliative care and hospice care provide comfort:
- Palliative care can begin at diagnosis, and can be given at the same time as treatment.
- Hospice care is usually offered when the patient is expected to live 6 more months or fewer