21 Current Concepts in Management of Congestive Heart Failure

Abstract: Congestive heart failure is a clinical syndrome resulting from inability of the heart to pump adequate amount of blood to meet the demands of the body. Main causes include CAD, HT, DM, VHD, anemia, and alcohol. LV injury causes LV remodeling, reduced EF, arrhythmias, sudden cardiac deaths and increased mortality. The ACC/AHA classification focuses on pathophysiology and is complimentary to NYHA classification emphasizing on the aggressive management of risk factors. Main drugs are ACEIs, BBs, ARBs, diuretics, aldosterone blockers and digoxin. ACEI and BBs reduce mortality, prevent, delay or reverse LV remodeling. ACEIs are recommended in all patients as first-line therapy, with or without symptoms to improve survival, symptoms, functional capacity, and reduction of hospitalizations. BBs are the second most important drugs even in concomitant DM, PVD. ARBs can be an alternative to an ACEI, if patients cannot tolerate the latter. Diuretics are not the first line drug treatment in early stages if there are no signs of fluid retention. Aldosterone blockers are important to improve morbidity and mortality; they also reduce ventricular remodeling and myocardial fibrosis. Digoxin is indicated if HF persists despite optimal therapy with ACEI, BBs, and diuretics especially if patients have arrhythmias. CRT is recommended in advanced HF and wide QRS complex, already optimized on medical therapy. ICDs are indicated in CHF with EF less than 30%, on optimal medical therapy and serious arrhythmia. VADs originally intended for short-term use before transplantation, now with recent improvements might become more accessible to the class IV patients ineligible for cardiac transplantation. Treatment should also focus on lifestyle modifications, low sodium, low cholesterol diet, fluid restriction, compliance with medications, regular follow-up, weight management, regular exercise, supplemental oxygen, treatment of co-morbidities, aggressive treatment of HT, myocardial ischemia and lipid disorders, and avoidance of precipitating factors like infection, arrhythmias, physical or emotional stress, alcohol, NSAIDs, most CCBs and anti-arrhythmic agents. Long-term administration of positive inotropes is discouraged except for palliative reasons