Treatment Options When Heart Failure Worsens

By Michael Balk, MD, as told to John Donovan.

When we talk about heart failure, the first thing I do with people is ask a number of questions about diet and other potential conditions that may cause the heart failure. The most common probably is high blood pressure. Then there's coronary disease. Diabetes. Some viruses can affect the heart. Obesity probably has a big role. Sleep apnea is super common.

We have important data that these comorbidities -- conditions that are present with another condition -- affect the survival rates of people with heart failure. If you treat the obesity, treat the sleep apnea, treat the high blood pressure, you're likely to live longer.

So we have to go through all the sort of "normal" things that can cause heart failure. And there are some conditions that we call restrictive cardiomyopathies, too, buildup of materials inside the heart. Those are much more rare. (A cardiomyopathy is simply a disease of the heart.)

Once we determine causes, then we can get a better idea of treatment.

Different Paths

We break treatment down into categories. First, there's going to be the lifestyle modification category. Then there's the medication category. In particular, we use the term "Guideline Medical Therapy" to describe medications that have clearly been shown to improve survival, make people live longer, and lower the chances of hospitalization. In fact, doctors are held to a standard in prescribing these medications, for a reason: They work.

After that, we have more advanced therapies to prevent arrhythmias, or irregular heart rhythms. Those include things like defibrillators and pacemakers. And we have newer devices that weren’t available 20 years ago that can make people with weak hearts get better, if they have a particular type of heart disease called left bundle cardiomyopathy.

We also have advanced treatments which include:

• Heart transplantation
• Left ventricular assist devices (LVADs)
• IV drug therapy; certain intravenous medicines that we can give that seem to improve symptoms.

Sometimes we do those as a bridge to transplants, sometimes it's what we call destination therapy (when you're not a candidate for transplant). We might put one of these devices in, or give you a home infusion through an IV to keep you feeling well.

But it all starts with lifestyle.

A Change in How You Live

Diet is so important. Of course, how much salt you eat is the big one. We have a sort of general limit of 1,500 milligrams of sodium that we want people on. Lowering the salt lowers the amount of fluid that stays inside your body, lowers blood pressure, and makes it easier for your heart to pump blood.

Then, of course, there's exercise.

You think, "How does exercise work?" Well, when you think about heart failure, it's a supply-demand imbalance. Your heart can't pump enough blood for your body’s needs. But if you can make your body more efficient, you can get by with less.

It's no different than when we made cars smaller. You can’t put a 4-cylinder engine in a big old Cadillac and expect it to have enough power. If you have a heart that's pumping half as strong, it's analogous to running a 4-cylinder engine in a big car from the 1960s. It doesn't work so well. So if we work on doing more activity, we can make you more efficient and make a lot of progress there.

Once we talk about the initial sort of lifestyle things, we're going to go over what you need to do every day like:

• Watching your weight
• Looking for signs and symptoms of swelling in the legs
• Getting up every day
• Urinating
• Getting on the scale and checking your weight. I have many people that use their weight and symptoms to decide if they're going to take extra diuretics. They don't even mention it to me anymore. And that's great.

Finding the Right Medications

There are many types of medicines that doctors use to treat heart failure, including:

• ACE (angiotensin converting enzyme) inhibitors
• ARBs (angiotensin receptor blockers)
• Beta blockers
• Mineralocorticoid receptor agonists (MRAs)
• SGLT2 inhibitors
• Diuretics
• Vasodilators
• Ivabradine
• Vericiguat
• Digoxin

Diuretics help the body get rid of salt and water. They probably don't do much in terms of survival. They're there to treat the symptoms, to make you feel better. But many times we administer other medicines to make the heart stronger, and we won't have to give them as much diuretics.

We have a whole host of other medications that have just made a dramatic change. When I was a med student 35 years ago, you would never give a beta blocker to someone with heart failure. Never. It was thought they made hearts weaker. Well, it turns out blocking adrenaline, which is what a beta blocker does, actually improves survival. It makes the heart stronger, because blocking the adrenaline calms the heart down.

A medicine came out a number of years ago called carvedilol, which was just a life-changer when it came to heart failure. I can vividly remember in the early '90s giving medications like this thinking, "This makes no sense whatsoever." Ultimately, it became standard of care.

Only three beta blockers are what we consider Guideline Therapy. They work. Each has been shown independently to improve survival, make people live longer, make them feel better, and decrease their rate of re-hospitalization:

• Carvedilol (Coreg)
• Metoprolol (Toprol)
• Bisoprolol (Zebeta)

ACE inhibitors, and their sisters ARBs, lower blood pressure and make it easier for the heart to pump blood forward. We call that "unloading the heart." Those medicines, for probably 30 years now, we've known that they improve survival, make people live longer, and actually can make the heart shrink in size and can prevent the heart from getting worse.

Those medicines led to a newer medicine called a neprilysin inhibitor. It can lower blood pressure, and really improve how your heart works. It's pretty striking.

A couple more show some benefit. But these are the mainstays of therapy.

Remember, too, not all drugs are the same. There's actually another set of combinations of medicines that you can use instead of ACE inhibitors called hydralazine and nitrates. Those seem to do well with African Americans. Oftentimes, depending on the person, we basically customize their medical therapy.

Surgical Options

When you're talking about treatment, if your heart failure is due to a bad valve or a blockage, obviously we work on that, too. That's where surgery, say a valve replacement or an angioplasty, will sometimes help.

We can put in a pacemaker to control irregular heart rhythms. That can help. Implanted defibrillators, in most cases, are there to prevent sudden death. They monitor irregular heartbeats and can provide an electrical shock to fix them. But they don't actually make your heart stronger. There is a type of defibrillator we have now, a bi-ventricular pacemaker defibrillator (BiVICD, or biventricular implantable cardiac defibrillator), used for a specific kind of heart failure, that can improve sudden death rates and sometimes help your heart work better.

When you get to the next phase -- LVADs (the left ventricular assist devices) -- that's a big deal. You have to go inside the heart, you have to open the chest, etc. But, again, for people that are failing all the other things, that's an option, before a transplant.

Hope for Those With Heart Failure

Just in the last 30 years, there's been a fundamental change in how we approach heart failure, especially with respect to beta blockers. Seeing the heart work better … it used to blow our mind when we'd see an ejection fraction (a measurement of how well the heart is working) of 5 or 10%, something really bad. Then you put them on these medicines and we'd check back in 6 months and it's normal. That's so cool. And the heart shrinks. It starts off big and gets smaller. It gets better.

Wow.

There's lots of great stuff that we can do to make people feel better and live longer. And I think that's the important thing: that people should not give up hope. It's totally encouraging.

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