Congestive heart failure treatment of patients at high risk for developing heart failure (Stage A)


 * Saleh El Dassouki, M.D. [mailto:seldassouki@hotmail.com];

Overview
Early detection and mitigation of risk factors associated with the subsequent development of heart failure may have a tremendous impact on public and individual health.

Treatment of Hypertension
Controlling both systolic and diastolic hypertension has been associated with a significant reduction in the risk of subsequent HF. Control of systolic blood pressure is consistently associated with a 50% reduction in new heart failure. Other complications of hypertension include left ventricular hypertrophy (LVH), MI, stroke and sudden death. In the Framingham heart study, hypertension was present in 39% of men and in 59% of women with heart failure. These numbers emphasize the importance of managing hypertension at an early stage to avoid complications such as heart failure.

Lowering both systolic and diastolic blood pressure in accordance with the recommendations provided in published guidelines has proven its effectiveness in lowering systemic vascular resistance, improving ventricular remodeling and decreasing hemodynamic load on the failing ventricle in patients with established heart failure. The treatment of hypertension in patients with HF should take into consideration the type of heart failure that is present: In systolic dysfunction the biggest problem is the impaired contractility whereas in diastolic dysfunction, the main issue is the limitation of diastolic filling and therefore abnormal forward cardiac output due to increased ventricular stiffness.

When any anti-hypertensive regimen is prescribed, an important aspect to keep in mind is the presence of concomitant medical problems as CAD, diabetes, renal disease, pulmonary disease in many patients suffering from HF, which requires the health care providers to keep in mind the priority of lowering blood pressure while trying not to affect the treatment of those diseases.

Diuretic-based antihypertensive therapy has repeatedly been shown to prevent HF in a wide range of target populations. Patients may also benefit from the usage of ACE inhibitors(ACEIs) and beta blockers, which are proven to be effective in preventing HF in hypertensive individuals. However, ACEIs and beta blockers, as single therapies, are not superior to other antihypertensive drug classes in the reduction of all cardiovascular outcomes.

Nevertheless, among patients with diabetes and other cardiovascular complications, ACEIs have shown to reduce the onset of HF and progression of nephropathy. Another significant reduction of HF incidence in comparison to placebo in patients with type 2 diabetes mellitus and nephropathy has been achieved by the usage of ARB’s losartan and irbesartan. As previously mentioned an ultimate and appropriate hypertensive treatment would take into consideration all the concomitant diseases in an HF patient, and would involve multiple drugs used in combination.

===ACC/AHA Guidelines- Stage A- Treatment of Hypertension === {{cquote|

Class I
1. In patients at high risk for developing heart failure, systolic and diastolic hypertension should be controlled in accordance with contemporary guidelines. (Level of Evidence: A)

Class IIa
1. Angiotensin converting enzyme inhibitors can be useful to prevent heart failure in patients at high risk for developing heart failure who have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors. (Level of Evidence: A)}}

Treatment of Diabetes Mellitus
Diabetes increases the risk of HF in all patients groups whether coronary heart disease or hypertension is present and it may cause cardiomyopathy. A gender difference in terms of HF risk in diabetic patients is present, since the increase of HF for diabetic men is 3 times less than that for a diabetic woman. In a study of patients with type 2 diabetes mellitus over 50 years old, with urinary albumin greater than 20 mg/l, 4% of patients developed HF over the study period, of whom 36 % died. Health care providers should closely monitor hyperglycemia and target a certain blood glucose level to avoid end-organ complications in such patients since each 1% increase in (Hb)A1c is associated with an 8% increase risk of heart failure, and an (Hb)A1c > 10 increases the risk of CHF by 1.56 compared to an (Hb)A1c less than 7 ACEIs and ARBs have been proven to reduce the development of end-organ disease and the occurrence of clinical events in diabetic patients even when hypertension is not present. Long term treatment with ACEIs and ARBs has been shown to lower various dangerous complications in diabetic patients such as renal disease and prolonged treatment with ACEI ramipril has been shown to decrease the event of cardiovascular death, MI, and CHF. Long term therapy with ARBs has also been proven to lower cardiovascular complication, decreasing the incidence of first HF hospitalization and improving renal function in diabetic patients.

===ACC/AHA Guidelines- Stage A- Treatment of Diabetes Mellitus === {{cquote|

Class I
1. For patients with diabetes mellitus (who are all at high risk for developing heart failure), blood sugar should be controlled in accordance with contemporary guidelines. (Level of Evidence: C)

Class IIa
1. Angiotensin converting enzyme inhibitors can be useful to prevent heart failure in patients at high risk for developing heart failure who have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors. (Level of Evidence: A)

2. Angiotensin II receptor blockers can be useful to prevent heart failure in patients at high risk for developing heart failure who have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors. (Level of Evidence: C)}}

Management of Metabolic Syndrome
The metabolic syndrome or syndrome X is mainly linked to obesity (mainly abdominal obesity), insulin resistance, hypertriglyceridemia, low HDL, hypertension and fasting hyperglycemia. Those combined metabolic risks promotes vascular endothelial dysfunction, vascular inflammation and thus, the development of atherosclerotic cardiovascular disease. The major complication of metabolic syndrome is coronary artery disease which in turn increases the incidence of congestive heart failure in the general population; For this reason, the appropriate management of hypertension, diabetes mellitus, and dyslipedemia can significantly reduce the risk of developing CHF.

===ACC/AHA Guidelines- Stage A- Treatment of Metabolic Syndrome === {{cquote|

Class I
1. In patients at high risk for developing heart failure, systolic and diastolic hypertension should be controlled in accordance with contemporary guidelines. (Level of Evidence: A)

2. In patients at high risk for developing heart failure, lipid disorders should be treated in accordance with contemporary guidelines. (Level of Evidence: A)

3. For patients with diabetes mellitus (who are all at high risk for developing heart failure), blood sugar should be controlled in accordance with contemporary guidelines. (Level of Evidence: C)

4. In patients at high risk for developing heart failure who have known atherosclerotic vascular disease, healthcare providers should follow current guidelines for secondary prevention. (Level of Evidence: C)

Class IIa
1. Angiotensin converting enzyme inhibitors can be useful to prevent heart failure in patients at high risk for developing heart failure who have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors. (Level of Evidence: A)

2. Angiotensin II receptor blockers can be useful to prevent heart failure in patients at high risk for developing heart failure who have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors. (Level of Evidence: C)}}

Management of Atherosclerotic Disease
Atherosclerotic diseases (eg., of the coronary, cerebral, peripheral blood vessels) are an important risk factor in the development of CHF. A series of different large scale studies involving the long term usage of ACEIs, produced mixed data and recommendations. In one study, the treatment with ACEIs proved to decrease the risk of the primary endpoint of cardiovascular death, MI and stroke in patients with previous vascular disease who were without evidence of HF or reduced LVEF at the time of randomization, but the incidence of HF was not a primary or secondary endpoint, although it was improved. A more recent trial of ACEIs versus placebo didn’t prove to be effective in reducing the primary composite endpoint, although a post hoc analysis did show a decrease in HF hospitalization.

Those various findings led the AHA to change the level of recommendation for the use of ACEIs for stage A patients from Class 1 to Class 2a. Treatment of hyperlipidemia has also been shown to reduce the risk of death and of HF in patients with a history of MI.

===ACC/AHA Guidelines- Stage A- Treatment of Atherosclerotic Disease === {{cquote|

Class I
1. In patients at high risk for developing heart failure who have known atherosclerotic vascular disease, healthcare providers should follow current guidelines for secondary prevention. (Level of Evidence: C)

Class IIa
1. Angiotensin converting enzyme inhibitors can be useful to prevent heart failure in patients at high risk for developing heart failure who have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors. (Level of Evidence: A)

2. Angiotensin II receptor blockers can be useful to prevent heart failure in patients at high risk for developing heart failure who have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors. (Level of Evidence: C)}}

Control of Conditions That May Cause Heart Failure
Cardiotoxic effect of various agents and substances should be closely controlled, especially in patients at higher risk of developing HF. Smoking, alcohol, amphetamines, cocaine and other illicit drugs are some of the most common substances that patients should be advised about. Several HF programs limit alcoholic beverage consumption to no more than one alcoholic beverage a day for all the patients with LV dysfunction, regardless of cause. Cardiac injuries could be sustained from other causes and interventions, such as ionizing radiation involving the mediastinum, chemotherapeutic agents such as anthracyclines, immunotherapy such as trastuzumab, or high dose-cyclophosphamide. Trastuzumab in particular when combined with anthracyclines increase the risk of HF and may occur years after the initial exposure.

===ACC/AHA Guidelines- Stage A- Treatment of High Risk Patients === {{cquote|

Class I
1. Patients at high risk for developing heart failure should be counseled to avoid behaviors that may increase the risk of heart failure (e.g., smoking, excessive alcohol consumption, and illicit drug use). (Level of Evidence: C)

2. Ventricular rate should be controlled or sinus rhythm restored in patients with supraventricular tachyarrhythmias who are at high risk for developing heart failure. (Level of Evidence: B)

3. Thyroid disorders should be treated in accordance with contemporary guidelines in patients at high risk for developing heart failure. (Level of Evidence: C)

4. Healthcare providers should perform periodic evaluation for signs and symptoms of heart failure in patients at high risk for developing heart failure. (Level of Evidence: C)

5. Healthcare providers should perform a noninvasive evaluation of left ventricular function (i.e., left ventricular ejection fraction) in patients with a strong family history of cardiomyopathy or in those receiving cardiotoxic interventions. (Level of Evidence: C)

Class III
1. Routine use of nutritional supplements solely to prevent the development of structural heart disease should not be recommended for patients at high risk for developing heart failure. (Level of Evidence: C)}}

ACC/AHA Guidelines- Treatment of Patients at High Risk for Developing Heart Failure (Stage A)
{{cquote|

Class I
1. In patients at high risk for developing heart failure, systolic and diastolic hypertension should be controlled in accordance with contemporary guidelines. (Level of Evidence: A)

2. In patients at high risk for developing heart failure, lipid disorders should be treated in accordance with contemporary guidelines. (Level of Evidence: A)

3. For patients with diabetes mellitus (who are all at high risk for developing heart failure), blood sugar should be controlled in accordance with contemporary guidelines. (Level of Evidence: C)

4. Patients at high risk for developing heart failure should be counseled to avoid behaviors that may increase the risk of heart failure (e.g., smoking, excessive alcohol consumption, and illicit drug use). (Level of Evidence: C)

5. Ventricular rate should be controlled or sinus rhythm restored in patients with supraventricular tachyarrhythmias who are at high risk for developing heart failure. (Level of Evidence: B)

6. Thyroid disorders should be treated in accordance with contemporary guidelines in patients at high risk for developing heart failure. (Level of Evidence: C)

7. Healthcare providers should perform periodic evaluation for signs and symptoms of heart failure in patients at high risk for developing heart failure. (Level of Evidence: C)

8. In patients at high risk for developing heart failure who have known atherosclerotic vascular disease, healthcare providers should follow current guidelines for secondary prevention. (Level of Evidence: C)

9. Healthcare providers should perform a noninvasive evaluation of left ventricular function (i.e., left ventricular ejection fraction) in patients with a strong family history of cardiomyopathy or in those receiving cardiotoxic interventions. (Level of Evidence: C)

Class IIa
1. Angiotensin converting enzyme inhibitors can be useful to prevent heart failure in patients at high risk for developing heart failure who have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors. (Level of Evidence: A)

2. Angiotensin II receptor blockers can be useful to prevent heart failure in patients at high risk for developing heart failure who have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors. (Level of Evidence: C)

Class III
1. Routine use of nutritional supplements solely to prevent the development of structural heart disease should not be recommended for patients at high risk for developing heart failure. (Level of Evidence: C)}}

Vote on and Suggest Revisions to the Current Guidelines

 * The CHF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Guidelines Resources

 * The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult


 * 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation