Congestive Heart Failure (cont.)
Benjamin Wedro, MD, FACEP, FAAEM
Benjamin Wedro, MD, FACEP, FAAEM
Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.
Charles Patrick Davis, MD, PhD
Charles Patrick Davis, MD, PhD
Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.
In this Article
Until recently, the selection of medications available for the treatment of congestive heart failure was frustratingly limited and focused mainly on controlling the symptoms. Medications have now been developed that both improve symptoms, and, importantly, prolong survival.
Angiotensin Converting Enzyme (ACE) Inhibitors
ACE inhibitors have been used for the treatment of hypertension for more than 20 years. This class of drugs has also been extensively studied in the treatment of congestive heart failure. These medications block the formation of angiotensin II, a hormone with many potentially adverse effects on the heart and circulation in patients with heart failure. In multiple studies of thousands of patients, these drugs have demonstrated a remarkable improvement of symptoms in patients, prevention of clinical deterioration, and prolongation of survival. In addition, they have been recently been shown to prevent the development of heart failure and heart attacks. The wealth of the evidence supporting the use of these agents in heart failure is so strong that ACE inhibitors should be considered in all patients with heart failure, especially those with heart muscle weakness.
Possible side effects of these drugs include:
When used carefully with proper monitoring, however, the majority of individuals with congestive heart failure tolerate these medications without significant problems. Examples of ACE inhibitors include:
For those individuals who are unable to tolerate the ACE inhibitors, an alternative group of drugs, called the angiotensin receptor blockers (ARBs), may be used. These drugs act on the same hormonal pathway as the ACE inhibitors, but instead block the action of angiotensin II at its receptor site directly. A small, early study of one of these agents suggested a greater survival benefit in elderly congestive heart failure patients as compared to an ACE inhibitor. However, a larger, follow-up study failed to demonstrate the superiority of the ARBs over the ACE inhibitors. Further studies are underway to explore the use of these agents in congestive heart failure both alone and in combination with the ACE inhibitors.
Possible side effects of these drugs are similar to those associated with the ACE inhibitors, although the dry cough is much less common. Examples of this class of medications include:
Certain hormones, such as epinephrine (adrenaline), norepinephrine, and other similar hormones, act on the beta receptor's of various body tissues and produce a stimulative effect. The effect of these hormones on the beta receptors of the heart is a more forceful contraction of the heart muscle. Beta-blockers are agents that block the action of these stimulating hormones on the beta receptors of the body's tissues. Since it was assumed that blocking the beta receptors further depressed the function of the heart, beta-blockers have traditionally not been used in persons with congestive heart failure. In congestive heart failure, however, the stimulating effect of these hormones, while initially useful in maintaining heart function, appears to have detrimental effects on the heart muscle over time.
However, studies have demonstrated an impressive clinical benefit of beta-blockers in improving heart function and survival in individuals with congestive heart failure who are already taking ACE inhibitors. It appears that the key to success in using beta-blockers in congestive heart failure is to start with a low dose and increase the dose very slowly. At first, patients may even feel a little worse and other medications may need to be adjusted.
Possible side effects include:
Beta-blockers should generally not be used in people with certain significant diseases of the airways (for example, asthma, emphysema) or very low resting heart rates. While carvedilol (Coreg) has been the most thoroughly studied drug in the setting of congestive heart failure, studies of other beta-blockers have also been promising. Research comparing carvedilol directly with other beta-blockers in the treatment of congestive heart failure is ongoing. Long acting metoprolol (Toprol XL) is also very effective in individuals with congestive heart failure.
Digoxin (Lanoxin) has been used in the treatment of congestive heart failure for hundreds of years. It is naturally produced by the foxglove flowering plant. Digoxin stimulates the heart muscle to contract more forcefully. It also has other actions, which are not completely understood, that improve congestive heart failure symptoms and can prevent further heart failure. However, a large-scale randomized study failed to demonstrate any effect of digoxin on mortality.
Digoxin is useful for many patients with significant congestive heart failure symptoms, even though long-term survival may not be affected. Potential side effects include:
These side effects, however, are generally a result of toxic levels in the blood and can be monitored by blood tests. The dose of digoxin may also need to be adjusted in patients with significant kidney impairment.
Diuretics are often an important component of the treatment of congestive heart failure to prevent or alleviate the symptoms of fluid retention. These drugs help keep fluid from building up in the lungs and other tissues by promoting the flow of fluid through the kidneys. Although they are effective in relieving symptoms such as shortness of breath and leg swelling, they have not been demonstrated to positively impact long-term survival.
Nevertheless, diuretics remain key in preventing deterioration of the patient's condition thereby requiring hospitalization. When hospitalization is required, diuretics are often administered intravenously because the ability to absorb oral diuretics may be impaired, when congestive heart failure is severe. Potential side effects of diuretics include:
It is important to prevent low potassium levels by taking supplements, when appropriate. Such electrolyte disturbances may make patients susceptible to serious heart rhythm disturbances. Examples of various classes of diuretics include:
One particular diuretic has been demonstrated to have surprisingly favorable effects on survival in congestive heart failure patients with relatively advanced symptoms. Spironolactone (Aldactone) has been used for many years as a relatively weak diuretic in the treatment of various diseases. Among other things, this drug blocks the action of the hormone aldosterone.
Aldosterone has many theoretical detrimental effects on the heart and circulation in congestive heart failure. Its release is stimulated in part by angiotensin II (see ACE inhibitors, above). In patients taking ACE inhibitors, however, there is an "escape" phenomenon in which aldosterone levels can increase despite low levels of angiotensin II. Medical researchers have found that spironolactone (Aldactone) can improve the survival rate of patients with congestive heart failure. In that the doses used in the study were relatively small, it has been theorized that the benefit of the drug was in its ability to block the effects of aldosterone rather than its relatively weak action as a diuretic (water pill). Possible side effects of this drug include elevated potassium levels and, in males, breast tissue growth (gynecomastia).
Another aldosterone inhibitor is eplerenone (Inspra).
Medically Reviewed by a Doctor on 10/8/2013
Viewers share their comments
Congestive Heart Failure - Symptoms Question: For congestive heart failure, what were the symptoms and signs you experienced?
Congestive Heart Failure - Prognosis Question: What was your congestive heart failure prognosis?
Congestive Heart Failure - Treatment Question: What was the treatment for your congestive heart failure?
Congestive Heart Failure - Causes Question: What are the underlying causes of your congestive heart failure?