Living with Heart Failure:
Patients with heart failure have to make adjustments to manage symptoms.
It is important to remain active, but patients may need additional rest or take naps during the day. Patients with heart
failure will often feel exhausted after just a little bit of work, and may need to apply for disability. Patient need
to monitor symptoms and weight carefully. If weight gain is not treated, symptoms can quickly worsen and patients will
require urgent treatment or hospitalization.
One of the most important aspects of managing heart failure is balancing fluid volume.
It is important to weigh every day, and the dose of water pills may need to be adjusted for weight gain or loss. Patients
with heart failure need to avoid excess salt, as it causes fluid and weight gain. Salt is present in most foods, so
knowledge of which foods to avoid and reading labels is very important. In general, patients with heart failure
should keep sodium levels below 2,000 mg per day.
Another factor that may contribute to worsening heart failure is anti-inflammatory medications,
such as ibuprofen (Motrin) or naproxen (Aleve). These medications may promote salt and water retention. Tylenol
is generally safe to use for pain.
Laboratory testing is required on a regular basis to monitor kidney function and electrolytes.
The frequency of testing and physician check-ups will depend on the severity of heart failure.
Symptoms of Heart Failure:
Symptoms of heart failure include fatigue, shortness of breath, edema (swelling),
abdominal fullness or pain, loss of appetite, waking up at night with shortness of breath, using extra pillows at night to
breathe better, cough and chest pain.
Medication for Heart Failure:
Medications are given to help patients feel better, live longer, and stay
out of the hospital. The vast majority of studies have evaluated patients with systolic heart failure and ejection fraction
of less than 40%. The effect of these medications in other types of heart failure are less certain. There are
three important medications to take in heart failure long-term, and a number of additional medications to be considered in
some patients.
The most effective medication for systolic heart failure is a beta-blocker.
Beta-blockers block adrenaline, which may be present in the blood at abnormally high levels. Initially beta-blockers
may cause patients to feel tired, or lower the blood pressure too much. Therefore, it is important to start at low doses
and increase the medication slowly. Most patients will tolerate these medications well, but some patients may never
reach the highest dose level. Beta-blockers have consistently shown improvement in heart function, a decrease in rhythm
problems, a decrease the chance of worsening heart failure or admission to the hospital, improved survival, and an improvement in
symptoms. Beta-blockers usually cannot be given to patients with asthma or very slow heart rates. The best studied
beta-blockers are carvedilol (Coreg) and metoprolol succinate (Toprol XL). Coreg is a little more effective at improving
heart function and it provides more complete beta-blockade, but some patients tolerate one medication better than the other,
and both are very effective in treating heart failure. Other beta-blockers, such as atenolol, are used commonly,
but of uncertain benefit.
The next class of medication that is vital to treatment of heart failure
are ACE-inhibitors. This group of medications blocks the production of angiotensen, a blood vessel constrictor.
These medications are well researched, and do improve heart function, symptoms, and outcomes in heart failure.
These medications can rarely cause a cough, high potassium levels, low blood pressure, rash or other side effects, but generally
are well tolerated. Common ACE-inhibitors are lisinopril (Zestril), enalapril (Vasotec), ramipril (Altace), benazapril
(Lotensen), perindopril (Aceon), captopril, moexipril (Univasc), quinapril, and fosinopril. Related medications
called angiotensen blockers, block the effects of angiotensin on the receptor, rather than block production. Examples
are Atacand, Diovan, Cozaar, Hyzaar, Benicar, and Avapro. These medications are an acceptable substitute if patients
cannot tolerate ACE-inhibitors, and are unlikely to cause side effects. Sometimes these medications are added in addition
to ACE-inhibitors, as one study with Atacand demonstrated reduction in hospitalizations and death from heart failure.
The third group of medications that can improve heart function, symptoms,
and survival are aldosterone blockers, such as spironolactone. This medication may cause nausea or breast
tenderness in some patients, and if not tolerated, a newer medication, eplerenone (Inspra), can be used. These medications
block aldosterone, another harmful hormone in heart failure. These medications are a weak diuretic (water pill) and
help raise potassium levels. Laboratory test need to be monitored carefully in patients with any kidney function
problems.
One of the most common medications used in heart failure are diuretics.
The most common diuretic is furosemide (Lasix), which removes excess fluid and helps with symptoms of shortness of breath.
Randomized trial have not been performed, but diuretics definitely improve symptoms and help prevent hospital admissions
in patients with excess fluid retension. Diuretics are essential to use when needed, but may be stopped once
the heart failure is controlled with other medications. Sometime a booster diuretic is used, called metolazone
(Zaroxolyn), but often depletes potassium and magnesium levels. Another diuretic, torsemide (Demadex) is a little more
effective at removing fluid and may improve heart function and symptoms compared to Lasix. HCTZ is a weak diuretic,
and not very effective in advanced heart failure. Potassium levels and the patient's weight need to be monitored carefully
while on diuretics.
Digoxin is a common medication used in heart failure. Digoxin
was the original treatment of heart failure, and drinks were once made from the foxglove plant for this ingredient.
Digoxin is very effective in improving symptoms of heart failure, and may also improve survival if the levels
are maintained between 0.5 and 0.9 mg/dL. Digoxin can worsen heart rhythm problems, especially when levels are elevated.
This may be more common in women, and should be used with caution. High levels may cause nausea, anorexia, or vision
changes.
Isosorbide and hydralazine are additional blood pressure medications that
may be effective in improving heart failure symptoms and reducing the chance of death. These medications are especially
important in patients who cannot take ACE-inhibitors, or have severe heart failure.
Cholesterol medications, especially statins, may improve survival in heart failure. These
medications reduce inflammation and may reduce rhythm problems. Patients taking these medications live longer than patients
not on these medications, regardless if coronary artery disease is present or not. Large randomized trials are underway.
Several other medications have shown some improvement in heart failure outcomes
or symptoms in small trials, but are generally not used routinely. Most patients find it difficult enough to take the
above medications and carefully titrate to the optimal dose.
Pacemakers in Heart Failure
Pacemakers may be helpful in selected patients with heart failure. Some patients may have
asynchrony, or a delay in electrical activation from one side of the heart to the other. These patients may feel better
with a special pacemaker to restore the electrical conduction. See biventricular pacing. Special defibrillator pacemakers may also improve the chance of survival in patients with heart failure with a high risk of rhythm problems.
